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 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 plan's contracted suppliers provide access to all preferred DME brands; - During an enrollee's 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 in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, 10.12.2. The rules say blood glucose monitors are meter devices that read color changes produced on specially treated reagent strips by glucose concentrations in the patient's blood. The patient, using a disposable sterile lancet, draws a drop of blood, places it on a reagent strip and, following instructions which may vary with the device used, inserts it into the device to obtain a reading. Lancets, reagent strips, and other supplies necessary for the proper functioning of the device are also covered for patients for whom the device is indicated. Home blood glucose monitors enable certain patients to better control their blood glucose levels by frequently checking and appropriately contacting their attending physician for advice and treatment. Studies indicate that the patient's ability to carefully follow proper procedures is critical to obtaining satisfactory results with these devices. In addition, the cost of the devices, with their supplies, limits economical use to patients who must make frequent checks of their blood glucose levels. Accordingly, coverage of home blood glucose monitors is limited to patients meeting the following conditions:
1. The patient has been diagnosed as having diabetes; 2. The patient's physician states that the patient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases, the patient may not be able to perform this function, but a responsible individual can be trained to use the equipment and monitor the patient to assure that the intended effect is achieved. This is permissible if the record is properly documented by the patient's physician; and 3. The device is designed for home rather than clinical use. There is also a blood glucose monitoring system designed especially for use by those with visual impairments. The monitors used in such systems are identical in terms of reliability and sensitivity to the standard blood glucose monitors described above. They differ by having such features as voice synthesizers, automatic timers, and specially designed arrangements of supplies and materials to enable the visually impaired to use the equipment without assistance. These special blood glucose monitoring systems are covered under Medicare if the following conditions are met: The patient and device meet the three conditions listed above for coverage of standard home blood glucose monitors; and The patient's physician certifies that he or she has a visual impairment severe enough to require use of this special monitoring system. The additional features and equipment of these special systems justify a higher reimbursement amount than allowed for standard blood glucose monitors. Separately identify claims for such devices and establish a separate reimbursement amount for them. You can find this information in Medicare's National Coverage Determination (NCD): Home Blood Glucose Monitors (40.2).
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 health plan contract says that Abbott and Lifescan glucometers, diabetic test strips, lancets, control solutions and a continuous glucose monitoring device are available for dispense via a retail or mail order pharmacy. All the other desired brands will need to be obtained from a durable medical equipment (DME) supplier (or via an exception process). You can find this information in Chapter 4 on page 68 of the plan's 2022 Evidence of Coverage.