Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
For a beneficiary who is not currently being treated with insulin administrations, more than 100 test strips and 
more than 100 lancets every 3 months are covered if criteria (a)  (c) below are met. 
For a beneficiary who is currently being treated with insulin administrations, more than 300 test strips and 
more than 300 lancets every 3 months are covered if criteria (a)  (c) below are met. 
a. Basic coverage criteria (1)-(2) listed above for all home glucose monitors and related accessories and 
supplies are met; and, 
b. Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization 
guidelines, the treating practitioner has had an in-person visit with the beneficiary to evaluate their 
diabetes control and their need for the specific quantity of supplies that exceeds the usual utilization 
amounts described above; and, 
c. Every six (6) months, for continued dispensing of quantities of testing supplies that exceed the usual 
utilization amounts, the treating practitioner must verify adherence to the high utilization testing 
regimen. 
If neither basic coverage criterion (1) or (2) is met, all testing supplies will be denied as not reasonable and 
necessary. If quantities of test strips or lancets that exceed the utilization guidelines are provided and criteria 
(a)  (c) are not met, the amount in excess will be denied as not reasonable and necessary. 
You can find this rule in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
The rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing 
for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the 
following conditions are met (42 CFR 422.100(l)): 
 
1. The MA plan provides all categories of DME covered under original Medicare Part B; 
2. The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
3. The MA plans contracted suppliers provide access to all preferred DME brands; 
4. During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 
90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and 
repairs, as applicable) non-preferred DME brands furnished in the previous year; 5. Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
6. The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
7. The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a nonpreferred 
DME product or brand with the EOC and ANOC and on its website; and 
8. The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by CMS to require full coverage. 
 
You can find this rule at the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 10.12.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.  The Plan 
contract says we cover diabetic supplies made by a specific brand. We exclusively cover a specific brand of  
glucose monitors and test strips. Prior authorization is required for more than one blood glucose monitor per 
year and/or test strips in excess of 100 strips per 30 days. You can find this information on pages 68-69 of the 
Plans 2022 Evidence of Coverage.