Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and coinsurances for physician, durable 
medical equipment, Part B drug, and physical therapy services provided from April 17, 2020 to September 28, 
2020. 
 
You asked the Plan to waive the copayments and coinsurances for these services. You say that you were not 
given correct information when you enrolled, and you did not know that any of these providers were 
considered out-of-network. The Plan denied your request. The Plan says you were charged the correct amounts 
according to the Plan contract. 
 
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 a 20% 
coinsurance for durable medical equipment (DME) and related supplies, a 20% coinsurance for Part B drugs, a 
$35 copayment for in-network outpatient therapy, and a $45 copayment for a specialist office visit and for 
physician services provided in-network. Please note that while some of the providers in question are considered 
out-of-network, the Plan has acknowledged that you were referred to their care by a Plan-contracted provider 
and is billing you the in-network rate. 
 
You have been asked to pay $24.29 for a knee orthosis. The Plan?s allowed amount for a knee orthosis is 
$121.46 ($121.46 x 20% = $24.29). A knee orthosis falls within the durable medical equipment (DME) benefit 
category. You have been asked to pay 20% coinsurance. This means that you have been asked to pay the 
correct amount based on your contract with the Plan.  
 
You have been asked to pay $31.82 for Bevacizumab injections, which falls within the Part B drug benefit 
category. The Plan?s allowed amount for a Bevacizumab injection is $159.12, and Part B drugs have a 20% 
coinsurance ($159.12 x 20% = $31.82). This means that you have been asked to pay the correct amount based 
on your contract with the Plan. 
 
You also received multiple sessions of outpatient rehabilitation services, including therapeutic exercises, self-
care management training, and gait training therapy. Outpatient rehabilitation services are subject to a $35 
copayment when provided in-network. The Plan charged you $35 for each day that you received outpatient 
therapy. When more than one therapy procedure is performed on the same day by the same provider, the 
copayment for these services is collective. Therefore, you have been asked to pay the correct amount for the 
outpatient therapy services. 
 
The Plan has asked you to pay a $45 copay for each visit with a specialist and $45 for each injection service, 
both of which fall within the physician/practitioner services benefit category. You are charged a copayment for 
each because an office visit is one specific service and an injection service provided by the specialist at the time 
of a visit are two separate, billable services. Therefore, you have been asked to pay the correct cost-sharing 
amounts for these services provided by a specialist. 
 
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 copayments and coinsurances for physician, durable medical 
equipment, Part B drug, and physical therapy services provided from April 17, 2020 to September 28, 2020.  
 
Your complaint about confusion and possible misinformation when you signed up for your Plan is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.