Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
(J7030, J2405, J1650) received on December 20 to December 22, 2019, for Medicare Part B prescription drugs 
(J1885, J1650, J2785) received on January 9 to January 11, 2020, or for Medicare Part B prescription drugs 
(J7030, J3010, J2250, J2370) received on January 28, 2020. The Plan does not have to waive the copayment for 
intravenous injection (96374) performed on January 9 to January 11, 2020, or for catheter placement (93458) 
performed on January 28, 2020. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs and to waive the 
copayments for intravenous injection and catheter placement. You say that you were admitted to the hospital 
for each emergency room visit and should not be charged the emergency room copayment. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. Your contract also says that enrollees must pay a $75 
copayment for Medicare-covered emergency services and a $100 copayment for outpatient surgery. 
 
Regarding the request to waive the coinsurance for Medicare Part B prescription drugs: you have been asked to 
pay $30.04, or 20% coinsurance of the Plan-allowed amount of $150.20, for Medicare Part B prescription 
drugs received on December 20 to December 22, 2019. You have been asked to pay $136.64, or 20% 
coinsurance of the Plan-allowed amount of $683.20, for Medicare Part B prescription drugs received on 
January 9 to January 11, 2020. You have been asked to pay $19.48, or 20% coinsurance of the Plan-allowed 
amount of $97.40, for Medicare Part B prescription drugs received on January 28, 2020. 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 Medicare Part B prescription drugs (J7030, J2405, J1650) received 
on December 20 to December 22, 2019, for Medicare Part B prescription drugs (J1885, J1650, J2785) received 
on January 9 to January 11, 2020, or for Medicare Part B prescription drugs (J7030, J3010, J2250, J2370) 
received on January 28, 2020. 
 
Regarding the request to waive the copayment for intravenous injection performed in the emergency room on 
January 9 to January 11, 2020: you have been asked to pay a $75 copayment for intravenous injection. When 
administered in the emergency room, intravenous injection falls within the Emergency care benefit category. 
There is no evidence in the case record that you were admitted to the hospital on an inpatient basis. 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 intravenous injection (96374) received on January 9 to January 11, 
2020. 
 
Regarding the request to waive the copayment for catheter placement: you have been asked to pay a $100 
copayment for catheter placement. Catheter placement in a hospital facility/setting falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 catheter placement (93458) received on January 
28, 2020.