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. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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)): 
 
The MA plan provides all categories of DME covered under original Medicare Part B; 
The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
The MA plans contracted suppliers provide access to all preferred DME brands; 
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; 
Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred 
DME product or brand with the EOC and ANOC and on its website; and 
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 information at Medicare Managed Care Manual Chapter 4 - Benefits and Beneficiary 
Protections 10.12.2- Specifying Brands or Manufacturers of DME. 
 
 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 Health 
Plan contract says that diabetic testing supplies obtained through the pharmacy are limited to Ascencia branded 
products (Breeze and Contour) and LifeScan branded products (OneTouch Verio Flex, OneTouch Verio 
Reflect, OntTouch Verio, OneTouch Ultra Mini and OneTouch Ultra 2). Prior approval will be required for any 
other brands of meters and test strips. Yu can find this information on page 67 of the Plan's 2022 EOC.