Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the therapeutic injection (96375) and the chemotherapy administration (96413). We decided that the Plan does not have to waive the coinsurance for the abatacept injection (J0129).
You asked the Plan to reduce the coinsurance for the therapeutic injection (96375), the chemotherapy administration (96413), and the abatacept injection (J0129). You say that you are being billed for the infusion therapy incorrectly. The Plan says that you have been asked to pay the correct cost-sharing amount. The Plan says the 20% coinsurance includes the administration of drugs in all places of treatment, including chemotherapy and Medicare Part B covered drugs.
We decided that the Plan has to waive the coinsurance for the therapeutic injection (96375) and the chemotherapy administration (96413).
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms how much you should expect to pay for provider and professional services at an in-network outpatient hospital. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% for the therapeutic injection (96375) and the chemotherapy administration (96413). The Plan contract does not clearly say how much enrollees must pay a facility for provider and professional services at an in-network outpatient hospital. The record shows codes 96375 and 96413 are considered physician services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for the therapeutic injection (96375) and the chemotherapy administration (96413) provided on February 2, 2021.
The Plan says that you must pay $13.89 for the therapeutic injection (96375) and $53.95 for the chemotherapy administration (96413). Based on the plan contract, however, you cannot be asked to pay more than a $0 copayment for the therapeutic injection (96375) and the chemotherapy administration (96413). Therefore, we decided that the provider has to waive the coinsurance for each service to $0.
We also decided that the Plan does not have to waive the coinsurance for the abatacept injection (J0129).
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $586.35 which is less than the standard 20% of the allowed amount for the abatacept injection (J0129). The allowed amount is $3,118.28. Therefore, we decided that the Plan does not have to waive the coinsurance for the abatacept injection (J0129).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.