Appeal type: Surgery
Decision: Partially Favorable

 
You asked the Plan to waive the cost-sharing for cochlear implant surgery, a cochlear implant, unidentified 
pharmacy charges, and unidentified supply charges provided on June 6, 2022.. You say that you would 
appreciate reversal of these charges. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the cost-sharing for unidentified pharmacy and supply charges.  
 
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. The Plan did not provide identification of the charges billed with hospital 
revenue codes 0250 and 0270, such as a Current Procedural Terminology (CPT) code or description of the 
specific items/services for which these revenue codes have been billed. Without specific identification of the 
items/services represented by these charges, we cannot determine which cost-sharing benefit  if any  is 
applicable to these charges. Therefore, the Plan has not shown that its decision to ask you to pay a total amount 
of $2,695.13 coinsurance for these charges is correct or justified according to your contract with the Plan. 
Therefore, we decided that the Plan has to waive the cost-sharing for unidentified pharmacy and supply 
charges.  
 
We also decided that the Plan does not have to waive the cost-sharing for cochlear implant surgery and 
cochlear implant. 
 
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 $750 
deductible and 40% coinsurance for out-of-network cochlear implant surgery and 25% coinsurance for an out-
of-network cochlear implant. At the time this claim was processed, $195.94 of the $750 deductible had been 
met. The allowed amount of the cochlear implant surgery is $15,570.00, resulting in a deductible amount of 
$554.06 because this met the $750 total deductible for 2022. The remaining allowed amount of the cochlear 
implant surgery is $15,015.94, resulting in a coinsurance amount of $6,006.38. The allowed amount of the 
cochlear implant is $10,320.06, and you have been asked to pay $199.53 which is less than 25% coinsurance 
for the cochlear implant. Therefore, your total cost-sharing amount is $6,759.97. Therefore, we decided that the 
Plan does not have to waive the cost-sharing for cochlear implant surgery and cochlear implant. 
 
Therefore, we decided that the Plan has to reduce your total cost-sharing amount from $9,455.10 to $6,759.97. 
 
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.