Appeal type: Practitioner Services
Decision: Partially Favorable

 
You asked the Plan to waive the cost-sharing for inpatient hospital care, unidentified items/services, Medicare 
Part B prescription drugs, an ultrasound, an echocardiogram, a computed tomography (CT) scan, outpatient 
surgical services, and physician visits provided from December 31, 2021, to September 13, 2022. You say that 
the Plan should pay all of your remaining bills because you have already exceeded the $4,900 maximum out-
of-pocket amount. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the cost-sharing for an inpatient stay provided from December 31, 
2021, to January 4, 2022 and unidentified items/services provided on unknown dates. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Medicare rules say that the plan that covered the enrollee at the 
beginning of an inpatient stay is responsible for the entire stay. The Plan must follow Medicare rules. The rules 
say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE 
information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. You received inpatient hospital care beginning on December 31, 2021. By rule, 
this means that coverage of this stay should apply to your 2021 plan-year benefits. The Plan did not submit a 
copy of the applicable 2021 Evidence of Coverage (EOC). Without this information, we cannot determine 
whether the cost-sharing amount you are being asked to pay is correct or justified according to your contract 
with the Plan. Furthermore, the Plan did not submit any evidence needed to determine what your 2021 
maximum out-of-pocket amount was and whether it had been met at the time this claim was processed. 
Therefore, the Plan has not shown that its decision to ask you to pay $750 copayment for this inpatient stay is 
correct or justified according to Medicare rules and your contract with the Plan. 
 
You have also been asked to pay cost-sharing for items and/or services which the Plan has not identified. You 
were asked to pay $5.70 for Plan claim number 820221710638514. You were asked to pay $4.92 for Plan claim number 820221890557878. You were asked to pay $4.92 for claim number 820222420443173. You were 
asked to pay $4.92 for claim number 820222830168083. Without identification of the items and services 
involved in these claims, the Plan has not shown that any cost-sharing amounts are applicable to these claims. 
 
A summary of the cost-sharing amounts that the Plan must waive follows: 
 
Claim Number Date(s) of Service Service Provided 
Amount you were 
asked to pay 
820220110518976 
December 31, 2021, to 
January 4, 2022 
Inpatient Hospital 
Stay 
$750 
820221710638514 Unknown Unknown $5.70 
820221890557878 Unknown Unknown $4.92 
820222420443173 Unknown Unknown $4.92 
820222830168083 Unknown Unknown $4.92 
Total   $770.46 
  
Consequently, because these cost-sharing amounts are waived they no longer apply to your 2022 maximum 
out-of-pocket amount. Therefore, we decided that the Plan has to waive the cost-sharing for inpatient stay and 
unidentified items/services.  
 
We also decided that the Plan does not have to waive the cost-sharing for inpatient hospital care 
provided in 2022, Part B drugs, ultrasound, echocardiogram, CT scan, outpatient surgeries, and 
physician visits. 
 
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 $250 
copayment per day for days 1 to 5 of inpatient hospital care, 20% coinsurance for Part B drugs including 
administration, $30 copayment for ultrasound, $30 copayment for echocardiogram, $250 copayment for CT 
scan, $250 copayment for each outpatient surgery at an outpatient hospital, and $30 copayment for each 
specialist physician visit, up to a maximum out-of-pocket amount of $4,900. A summary of your cost-sharing 
amounts follows, which will be divided into separate tables and totaled thereafter: 
 
Table A 
Date(s) of Service Service Provided 
Allowed 
Amount 
Cost-Share Per 
Contract 
Your Cost-Share 
Amount 
January 5, 2022 to 
January 10, 2022 
Ertapenem Sodium 
Injections 
$293.76 20% coinsurance $58.74 
January 11, 2022 to 
January 15, 2022 
Ertapenem Sodium 
Injections 
$171.36 20% coinsurance $39.17 
January 14, 2022 
Catheter Drainage 
Surgery 
$2,996.10 $250 copayment $250 
January 16, 2022 to 
January 18, 2022 
Ertapenem Sodium 
Injections 
$146.88 20% coinsurance $29.37 
Total  Table A    $377.28 
  Table B 
Date(s) of Service Service Provided 
Allowed 
Amount 
Cost-Share Per 
Contract 
Your Cost-Share 
Amount 
January 19, 2022 to 
January 21, 2022 
Ertapenem Sodium 
Injections 
$146.88 20% coinsurance $29.37 
January 22, 2022 to 
January 25, 2022 
Ertapenem Sodium 
Injections 
$195.84 20% coinsurance $39.16 
January 26, 2022 to 
January 28, 2022 
Ertapenem Sodium 
Injections 
$146.88 20% coinsurance $29.37 
January 29, 2022 to 
January 31, 2022 
Ertapenem Sodium 
Injections 
$146.88 20% coinsurance $29.37 
February 1, 2022 
Ertapenem Sodium 
Injection 
$48.96 20% coinsurance $9.79 
February 2, 2022 
Catheter Drainage 
Surgery 
$2,996.10 $250 copayment $250 
February 3, 2022 to 
February 4, 2022 
Ertapenem Sodium 
Injections 
$97.92 20% coinsurance $19.58 
February 5, 2022 to 
February 8, 2022 
Ertapenem Sodium 
Injections 
$195.84 20% coinsurance $39.16 
February 9, 2022 Specialist Visit $121.27 $30 copayment $30 
February 9, 2022 to 
February 10, 2022 
Ertapenem Sodium 
Injections 
$97.92 20% coinsurance $19.58 
February 11, 2022 to 
February 14, 2022 
Ertapenem Sodium 
Injections 
$195.84 20% coinsurance $39.16 
February 15, 2022 
Ertapenem Sodium 
Injection 
$48.96 20% coinsurance $9.79 
February 22, 2022 to 
February 25, 2022 
Inpatient Hospital 
Stay 
$6,893.12 
$250 copayment 
per day for 
days 1 to 5 
$500 
February 26, 2022 to 
February 27, 2022 
Ertapenem Sodium 
Injections 
$146.88 20% coinsurance $29.38 
February 28, 2022 
Daptomycin 
Injection 
$20 20% coinsurance $4 
March 1, 2022 to 
March 5, 2022 
Anidulafungin and 
Daptomycin 
$271 20% coinsurance $54.20 
March 2, 2022 
Anidulafungin 
Injection 
$57 20% coinsurance $11.40 
March 3, 2022 
Anidulafungin 
Injection 
$57 20% coinsurance $11.40 
March 6, 2022 to 
March 11, 2022 
Anidulafungin and 
Daptomycin 
$385 20% coinsurance $77 
March 9, 2022 
Catheter Drainage 
Surgery 
$2,996.10 $250 copayment $250 
March 12, 2022 to 
March 14, 2022 
Anidulafungin and 
Daptomycin 
$231 20% coinsurance $46.20 
Total  Table B    $1,527.91 
  Table C 
Date(s) of Service Service Provided 
Allowed 
Amount 
Cost-Share Per 
Contract 
Your Cost-Share 
Amount 
March 15, 2022 to 
March 17, 2022 
Anidulafungin, 
Vancomycin, and 
Administration 
$216.77 20% coinsurance $43.34 
March 16, 2022 
Anidulafungin 
Injection 
$57 20% coinsurance $11.40 
March 17, 2022 
Anidulafungin 
Injection 
$57 20% coinsurance $11.40 
March 18, 2022 to 
March 20, 2022 
Anidulafungin, 
Vancomycin, and 
Administration 
$216.77 20% coinsurance $43.34 
March 19, 2022 
Anidulafungin 
Injection 
$57 20% coinsurance $11.40 
March 20, 2022 
Anidulafungin 
Injection 
$57 20% coinsurance $11.40 
March 21, 2022 to 
March 22, 2022 
Anidulafungin, 
Vancomycin, and 
Administration 
$205.65 20% coinsurance $41.12 
March 22, 2022 
Anidulafungin 
Injection 
$57 20% coinsurance $11.40 
March 23, 2022 Specialist Visit $121.27 $30 copayment $30 
March 23, 2022 to 
March 24, 2022 
Anidulafungin, 
Vancomycin, and 
Administration 
$205.65 20% coinsurance $41.12 
March 24, 2022 
Anidulafungin 
Injection 
$57 20% coinsurance $11.40 
March 25, 2022 
Anidulafungin 
Injection 
$57 20% coinsurance $11.40 
March 26, 2022 
Anidulafungin 
Injection 
$57 20% coinsurance $11.40 
March 25, 2022 to 
March 27, 2022 
Vancomycin and 
Administration 
$159.77 20% coinsurance $31.94 
March 27, 2022 
Anidulafungin 
Injection 
$57 20% coinsurance $11.40 
March 28, 2022 to 
March 29, 2022 
Anidulafungin, 
Vancomycin, and 
Administration 
$205.65 20% coinsurance $41.12 
March 29, 2022 
Anidulafungin 
Injection 
$57 20% coinsurance $11.40 
March 30, 2022 to 
March 31, 2022 
Anidulafungin, 
Vancomycin, and 
Administration 
$205.65 20% coinsurance $41.12 
March 31, 2022 
Anidulafungin 
Injection 
$57 20% coinsurance $11.40 
Total  Table C    $438.50 
  Table D 
Date(s) of Service Service Provided 
Allowed 
Amount 
Cost-Share Per 
Contract 
Your Cost-Share 
Amount 
April 1, 2022 to 
April 3, 2022 
Anidulafungin, 
Vancomycin, and 
Administration 
$220.29 20% coinsurance $44.05 
April 2, 2022 
Anidulafungin 
Injection 
$61 20% coinsurance $12.20 
April 3, 2022 
Anidulafungin 
Injection 
$61 20% coinsurance $12.20 
April 4, 2022 to 
April 5, 2022 
Anidulafungin, 
Vancomycin, and 
Administration 
$209.33 20% coinsurance $41.86 
April 6, 2022 to 
April 7, 2022 
Vancomycin and 
Administration 
$148.33 20% coinsurance $29.66 
April 7, 2022 Ultrasound $96.37 $30 copayment $30 
April 27, 2022 Specialist Visit $138.75 $30 copayment $30 
April 27, 2022 
Catheter Drainage 
Surgery 
$2,996.10 $250 copayment $250 
May 18, 2022 
Catheter Drainage 
Surgery 
$2,996.10 $250 copayment $250 
August 15, 2022 Specialist Visit $115.21 $30 copayment $30 
August 17, 2022 
Catheter Drainage 
Surgery 
$2,996.10 $250 copayment $250 
September 2, 2022 
Catheter Drainage 
Surgery 
$2,996.10 $250 copayment $250 
September 9, 2022 CT Scan $158.11 $250 copayment $158.11 
September 13, 2022 Echocardiogram $427.69 $30 copayment $30 
Total  Table D    $1,418.08 
 
  Table Totals 
Table 
Your Cost-Sharing 
Amount 
Table A $377.28 
Table B $1,527.91 
Table C $438.50 
Table D $1,418.08 
Grand Total $3,761.77 
 
Your total cost-sharing responsibility is therefore $3,761.77, which does not meet the $4,900 maximum out-of-
pocket amount for 2022. 
 
Therefore, we decided that the Plan does not have to waive the cost-sharing for inpatient hospital care provided 
in 2022, Part B drugs, ultrasound, echocardiogram, CT scan, outpatient surgeries, and physician visits. 
 
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.