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 MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing 
for the preferred brands or may limit the Durable Medical Equipment (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 Evidence of Coverage and Annual Notice of Change 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 in the Centers for Medicare and Medicaid Services (CMS) Medicare Managed 
Care Manual Chapter 4, Section 10.12.2- Specifying Brands or Manufacturers of DME. 
 
The payment amount for a given service or item, whether rented or purchased, must be consistent with what is 
reasonable and medically necessary to serve the intended purpose (See the Medicare Benefit Policy Manual, 
Chapter 15). Additional expenses for "deluxe" features, or items that are rented or purchased for aesthetic 
reasons or added convenience, do not meet the reasonableness test. Thus, where a service or item is medically 
necessary and covered under the Medicare program, and the patient wishes to obtain such deluxe features, the 
payment is based upon the payment amount for the kind of service or item normally used to meet the intended 
purpose (i.e., the standard item.) Usually this is the least costly item. DME Medicare Administrative Contractor 
(MACs) may, of course, determine that the payment amount for a more expensive service or item is reasonable 
when the additional expense is for an added feature that is medically necessary in a given case. For example, a 
more expensive item may be medically necessary where a patient in a weakened condition needs a power 
operated wheelchair or a power-operated vehicle that may be appropriately used as a wheelchair since the patient is not strong enough to operate a manual wheelchair. You can find this information in the Centers for 
Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-04, Medicare Claims 
Processing Manual Chapter 20, Section 90. 
 
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.