Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost sharing for the eye exams. We decided that the Plan does not 
have to waive the cost sharing for the retina imaging, the injection, and the drug administration.  
 
You asked the Plan to waive the cost sharing for the eye exam and the retina imaging provided on June 13, 
2022, and October 10, 2022, and the aflibercept injection and the drug administration provided on July 28, 
2022. You say that you think that the cost sharing for these services is too high. The Plan says that this cost 
sharing was charged correctly. 
 
We decided that the Plan has to waive the cost sharing for the eye exams.  
 
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 says that you pay a $0 copayment for 
each Medicare-covered eye exam. The Plan says you must pay a $10 copayment for each eye exam. Based on 
the Plan contract, however, you cannot be asked to pay more than $0 for each eye exam. Therefore, we decided 
that the Plan has to waive the cost sharing for the eye exams.  
 
We also decided that the Plan does not have to waive the cost sharing for the retina imaging, the 
injection, and the drug administration. 
 
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 $25 
copayment for Medicare-covered non-radiological diagnostic services, a 20% coinsurance for all other 
Medicare-covered Part B drugs, and a $50 copayment for Medicare-covered surgery or other services provided 
to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and 
physician or surgical charges. 
 
You have been asked to pay a $50 copayment for the retina imaging ($25 x 2 services = $50). These 
items/services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 
You have been asked to pay a $365.68 coinsurance for the injection ($1828.40 allowed amount x .20 = 
$365.68). This item/service falls within the Medicare Part B prescription drugs benefit category. You have also 
been asked to pay a $10 copayment for the drug administration because the Plan is only holding you 
responsible for this amount, which is less than the $50 copayment. This item/service falls with the outpatient 
surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. 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 retina imaging, the 
injection, and the drug administration. 
 
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.