Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit with an injection 
(99214, 20550) and for an ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection), imaging 
supervision and interpretation (76942), and the coinsurance for a methylprednisolone acetate injection (J1030) 
provided on November 30, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit with an injection and for an ultrasonic 
guidance for needle placement (eg, biopsy, aspiration, injection), imaging supervision and interpretation, and 
the coinsurance for a methylprednisolone acetate injection. You say that you will not be paying the bill for the balance of the November 30, 2021, visit. The Plan denied your request. The Plan says you were charged the 
correct cost sharing amount. 
 
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 $50 
copayment for office visits to specialists at an independent office. Your contract with the Plan also says that 
you must pay a 20% coinsurance plus any applicable copayment, depending on the location of service for 
Medicare Part B prescription drugs.  
 
You have been asked to pay a $50 copayment for a specialist office visit with an injection and for an ultrasonic 
guidance for needle placement (eg, biopsy, aspiration, injection), imaging supervision and interpretation. A 
specialist office visit with an injection and for an ultrasonic guidance for needle placement (eg, biopsy, 
aspiration, injection), imaging supervision and interpretation falls under physician/practitioner services, 
including doctors office visits. You have also been asked to pay $0.96 in coinsurance, which is 20% of the 
allowed amount for a methylprednisolone acetate injection ($4.78 allowed amount x 20% coinsurance = $0.96). 
A methylprednisolone acetate injection falls within the Medicare Part B prescription drugs 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 with an injection (99214, 20550) and 
for an ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection), imaging supervision and 
interpretation (76942), and the coinsurance for a methylprednisolone acetate injection (J1030) provided on 
November 30, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review. 
 
Your complaint about the potentially inadequate service at the physicians office on November 30, 2021, 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.