Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for a Privigen infusion (J1459) performed on May 26, 
2020. We also decided that the Plan has to waive the cost-sharing for a provider office visit (99213) on July 10, 
2020, for laboratory services (36415, 80069) received on July 6, 2020, and for laboratory services (36415, 
80048, 80061, 80076) received on August 7, 2020. We decided that the Plan does not have to waive the 
coinsurance for Privigen infusions (J1459) performed on May 18, June 1, June 8, June 15, and June 22, 2020, 
and for Methylprednisolone infusions (J2930) performed on May 19 and May 20, 2020.  
 
You asked the Plan to waive the coinsurance for Privigen infusions and Methylprednisolone infusions. You 
also asked the Plan to waive the cost-sharing for a provider office visit and for laboratory services. You say that 
you are appealing for a reduction in the amount of your bill. The Plan says that the correct cost-sharing was 
applied. 
 
We decided that the Plan has to waive the coinsurance for a Privigen infusion performed on May 26, 
2020, and to waive the cost-sharing for a provider office visit and for laboratory services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided an Explanation of Benefits (EOB) for May 26, 2020. 
The Plan has also not provided the 2020 Evidence of Coverage (EOC) in its entirety. The information provided 
by the Plan does not verify the coinsurance for date of service May 26, 2020, or the cost-sharing for a provider 
office visit or for laboratory services. Therefore, we decided that the Plan has to waive the coinsurance for a 
Privigen infusion performed on May 26, 2020, and to waive the cost-sharing for a provider office visit (99213) 
on July 10, 2020, for laboratory services (36415, 80069) received on July 6, 2020, and for laboratory services 
(36415, 80048, 80061, 80076) received on August 7, 2020. 
 
We also decided that the Plan does not have to waive the coinsurance for Privigen infusions performed 
on May 18, June 1, June 8, June 15, and June 22, 2020, and for Methylprednisolone infusions performed 
on May 19 and May 20, 2020. 
 
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 20% 
coinsurance for each Medicare-covered Part B drug.  
 
You have been asked to pay $535.81, or 20% of the Plan-allowed amount of $2,679.04, for a Privigen infusion 
on May 18, 2020, and $524.32, or 20% of the Plan-allowed amount of $2,621.59, for each Privigen infusion on 
June 1, June 8, June 15, and June 22, 2020. You have been asked to pay $34.92, or 20% of the Plan-allowed 
amount of $174.58, for each Methylprednisolone infusion on May 19 and May 20, 2020. Privigen infusions 
and Methylprednisolone infusions fall within the "Medicare Part B prescription drugs" benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for Privigen infusions (J1459) performed on May 18, June 1, 
June 8, June 15, and June 22, 2020, and for Methylprednisolone infusions performed on May 19 and May 20, 
2020. 
 
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.