Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an anesthetic injection (64418) and a 
trigger-point injection (20553) received on March 12, 2020. We also decided that the Plan does not have to 
waive the copayment for a specialist office visit (99213) on March 12, 2020, nor to waive the coinsurance for a 
Medicare Part B drug (J1030) received on March 12, 2020. 
 
You asked the Plan to waive the deductible for an anesthetic injection and a trigger-point injection. You also 
asked the Plan to waive the copayment for a specialist office visit and to waive the coinsurance for a Medicare 
Part B drug. You say that you were told by provider staff that there would be no charges. The Plan denied your 
request. The Plan says the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible that applies to outpatient surgery. The Plan contract 
also says that you must pay a $35 copayment for each specialist visit and 20% coinsurance for Medicare Part B 
prescription drugs. 
 
Regarding the request to waive the deductible for an anesthetic injection and a trigger-point injection: you have 
been asked to pay $116.10 toward your deductible for an anesthetic injection and a trigger-point injection. The 
items or services you asked the Plan to waive the deductible for fall within the benefit category outpatient 
surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible that applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met 
at the time that an anesthetic injection and a trigger-point injection were received on March 12, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for an anesthetic injection (64418) 
and a trigger-point injection (20553) received on March 12, 2020. 
 
Regarding the request to waive the copayment for a specialist office visit: you have been asked to pay a $35 
copayment for a specialist office visit. A specialist office visit falls within the "Physician/Practitioner services, 
including doctor's office visits" 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 copayment for a 
specialist office visit (99213) on March 12, 2020. 
 
Regarding the request to waive the coinsurance for a Medicare Part B drug: You have been asked to pay $1.25, 
or 20% of the Plan-allowed cost of $6.29, for a Medicare Part B drug. 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 a Medicare Part B drug (J1030) received on March 12, 2020. 
 
Your complaint about receiving erroneous or misleading information from provider staff 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.