Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the injection services rendered to you 
from July 1, 2020 to July 30, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the cost sharing was applied correctly. 
 
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 each in-network Medicare-covered Part B drug, a 40% coinsurance for each out-of-network 
Medicare-covered Part B drug, and a $125 copayment for each in-network Medicare-covered radiological 
diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. 
 
Review of the file shows that you received a Genvisc injection on July 1, 2020. You have been asked to pay a 
20% coinsurance for these services. These services fall within the in-network Medicare-covered Part B drug 
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.  
 
The file shows that you received an injection of contrast material for 10 dates of service from July 1, 2020 to 
July 30, 2020. The Plan has agreed to cover these services from an out-of-network provider at the in-network 
rate. You have been asked to pay a 20% coinsurance for these services. These services fall within the in-
network Medicare-covered Part B drug 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. 
The file shows that you received x-ray services for 10 dates of service from July 1, 2020 to July 30, 2020. The 
Plan has agreed to cover these services from an out-of-network provider at the in-network rate. You have been 
asked to pay a $125 copayment per date of service for these services. These services fall within the in-network 
Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a 
free-standing facility 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. 
 
The file shows that you received a Genvisc injection on eight dates of service from July 2, 2020 to July 30, 
2020. You have been asked to pay a 40% coinsurance for these services. These services fall within the out-of-
network Medicare-covered Part B drug 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 cost sharing for the injection services rendered 
to you from July 1, 2020 to July 30, 2020.