Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost share for the betamethasone acetate injections provided on 
October 1, 2020, October 27, 2020, August 16, 2022, and September 16, 2022, and the dexamethasone sodium 
injection provided on August 9, 2022. We also decided that the Plan does not have to waive the cost share for 
the hyaluronan injections provided from August 23, 2022, to September 13, 2022, and the specialist office 
visits provided from October 27, 2020, to September 16, 2022.  
 
You asked the Plan to waive the cost share for the injections and specialist office visits. You say that you 
should not be responsible to pay for these services. The Plan denied your request. The Plan says that this cost 
sharing was charged correctly. 
 
We decided that the Plan has to waive the cost share for the betamethasone acetate and dexamethasone 
sodium injections.  
 
You have been asked to pay 20% coinsurance for the betamethasone acetate and dexamethasone sodium 
injections. According to Medicare, betamethasone acetate injections (J0702) and dexamethasone sodium 
injections (J1100) are considered packaged codes and are not separately payable. Codes J0702 and J1100 are 
also excluded from the physicians fee schedule. Therefore, we decided that the Plan has to waive the cost 
share for the betamethasone acetate injections provided on October 1, 2020, October 27, 2020, August 16, 
2022, and September 16, 2022, and the dexamethasone sodium injection provided on August 9, 2022. 
 
We also decided that the Plan does not have to waive the cost share for the hyaluronan injections and 
specialist office 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 2020 contract with the Plan clearly says that you must pay a 
$45 copayment for in-network specialist office visits. Your 2022 contract with the Plan clearly says that you 
must pay a $50 copayment for in-network specialist office visits. Your 2022 contract with the Plan also clearly 
says that you pay 20% coinsurance for other in-network Medicare Part B drugs. 
 
You have been asked to pay a $45 copayment for the specialist office visit provided on October 27, 2020. You 
have also been asked to pay a $50 copayment for each specialist office visit provided from August 9, 2022, to 
September 16, 2022. These items/services fall within the physician/practitioner services benefit category.  
 
You have been asked to pay 20% coinsurance for the hyaluronan injections provided from August 23, 2022, to 
September 13, 2022. These items/services fall 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 cost share for the hyaluronan injections provided from August 23, 2022, to 
September 13, 2022, and the specialist office visits provided from October 27, 2020, to September 16, 2022. 
 
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.