Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urinalysis (81003) and the measurement of creatinine level in urine (82570) provided on April 6, 2021, and two injections of drugs into the eye (67028) provided on May 12, 2021, and June 23, 2021. We also decided that the Plan does not have to waive the coinsurance for a bevacizumab injection (J9035) provided on May 12, 2021, and a compounded drug injection (J7999) provided on June 23, 2021.
You asked the Plan to waive the copayment for the urinalysis, creatinine test, and eye injections. You also asked the Plan to waive the coinsurance for the injectable drugs. You say that page 69 of the EOC says there is no copayment nor coinsurance for blood tests for your condition and want to know why the provider is billing you. You also say that the claim shows you are being charged a coinsurance and do not see where it states you must pay a coinsurance in the EOC. You say you were not advised of this and believe page 98 of the EOC indicates your macular eye problem and diabetes are under a copayment.
The Plan denied your request. The Plan says none of the billed procedures qualify under the benefit categories you cite in your argument. The services on April 6, 2021, for urinalysis and creatinine test are not on the list of services covered under Diabetes Screening on page 69 of the EOC. Furthermore, the services on April 6, 2021, May 12, 2021, and June 23, 2021, for eye injections and injectable drugs are not eye exams. The services do not qualify for the $0 copayment for Medicare-covered eye exams as listed in the Vision Care benefit category on page 98 of the EOC.
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 $5 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies, a $50 copayment for Physician/Practitioner Services, and a 20% coinsurance for Medicare Part B Prescription Drugs. You have been asked to pay a cost-share of $165.90 for urinalysis, creatinine test, eye injections, and injectable drugs. The urinalysis and creatinine test fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The eye injections and injectable drugs fall within the Physician/Practitioner Services and Medicare Part B Prescription Drugs benefit categories, respectively. Urinalysis/Creatinine test = $5 copayment Eye injections = $50  2 dates of service = $100 copayment
Bevacizumab injection = Allowed Amount: $72.51  20% coinsurance = $14.50
Compounded drug injection = Allowed Amount: $232  20% coinsurance = $46.40
Total cost-share: $5 + $100 + $14.50 + $46.40 = $165.90 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 urinalysis (81003) and the measurement of creatinine level in urine (82570) provided on April 6, 2021, and two injections of drugs into the eye (67028) provided on May 12, 2021, and June 23, 2021. We also decided that the Plan does not have to waive the coinsurance for a bevacizumab injection (J9035) provided on May 12, 2021, and a compounded drug injection (J7999) provided on June 23, 2021.