Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on June 29, 2022, or waive the cost 
sharing for the Part B prescription drugs, medical supplies, and specialist visit rendered from August 22, 2022, 
to November 16, 2022. 
 
You asked the Plan to waive the cost sharing for these services. You say that you should not have any 
copayments. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The file shows that you received services from an out-of-network provider on June 29, 2022. The requested 
provider in this case is not a network provider with the Plan. The Plan had network providers available who 
could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at 
issue. We found no exception that would require the Plan to pay for these items/services. 
 
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% of 
the total cost for in-network Medicare Part B drugs, a 20% of the total cost for in-network durable medical 
equipment and supplies, and a $30 copayment for in-network specialist services. 
 
The file shows that you received medical supplies on August 22, 2022. You have been asked to pay 20% of the 
total cost for these services, for a total of $3.85. These services fall within the in-network durable medical 
equipment and supplies 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. 
 
The file shows that you received in-network specialist services on August 29, 2022; September 13, 2022; 
October 6, 2022; and November 14, 2022. The contract with the Plan states that there is a $30 copayment for 
in-network specialist services; however, the Plan applied a $21.50 copayment per date of service for these 
services, for a total of $64.50. 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. 
 
The file shows that you received medical supplies on August 29, 2022. You have been asked to pay 20% of the 
total cost for these services, for a total of $3.06. These services fall within the in-network durable medical 
equipment and supplies 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. 
 
The file shows that you received in-network specialist services on August 31, 2022; September 14, 2022; 
October 12, 2022; and November 16, 2022. You have been asked to pay a $30 copayment per date of service 
for these services, for a total of $120. These services fall within the in-network specialist services 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. 
 
The file shows that you received an injection of ferric carboxymaltose on August 22, 2022, and September 6, 
2022. You have been asked to pay 20% of the total cost for these services, for a total of $315.78. These 
services fall within the in-network Medicare Part B 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. 
 
The file shows that you received medical supplies on September 6, 2022. You have been asked to pay 20% of 
the total cost for these services, for a total of $2.24. These services fall within the in-network durable medical 
equipment and supplies 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. 
 
The file shows that you received medical supplies on September 13, 2022. You have been asked to pay 20% of 
the total cost for these services, for a total of $1.01. These services fall within the in-network durable medical 
equipment and supplies 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. 
 
The file shows that you received medical supplies on October 6, 2022. You have been asked to pay 20% of the 
total cost for these services, for a total of $.82. These services fall within the in-network durable medical 
equipment and supplies 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. 
 
The file shows that you received medical supplies on November 14, 2022. You have been asked to pay 20% of 
the total cost for these services, for a total of $.19. These services fall within the in-network durable medical 
equipment and supplies 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 pay for the office visit rendered on June 29, 2022, or 
waive the cost sharing for the Part B prescription drugs, medical supplies, and specialist visit rendered from 
August 22, 2022, to November 16, 2022.