Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost share for an OT visit provided on April 6, 2021. We also 
decided that the Plan does not have to waive the cost share for tissue pathology exams and Part B drugs and 
administration provided on April 6, 2021. We also decided that the Plan does not have to waive the cost share 
for lab services and Part B drugs and administration provided on August 4, 2021.  
 
You asked the Plan to waive the cost share for an OT visit, tissue pathology exams, lab services, and Part B 
drugs and administration. You say that you do not have any source of income and do not have a fund available 
to pay any bills. The Plan says that you have been charged the correct cost sharing amount. 
 
We decided that the Plan has to reduce the copayment for an OT visit provided on April 6, 2021.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $50 copayment for an out-of-network occupational visit.  
 
The Plan says you must pay the allowed amount of 112.60 for an OT visit. Based on the Plan contract, 
however, you cannot be asked to pay more than a $50 copayment for an OT visit. Therefore, we decided that 
the Plan has to reduce the copayment for an OT visit provided on April 6, 2021.  
 
We decided that the Plan does not have to waive the copayment for tissue pathology exams provided on 
April 6, 2021.  
 
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 $325 
copayment for outpatient surgery at an outpatient hospital. 
 
The tissue pathology exams are considered surgical services. You have been asked to pay a $325 for tissue 
pathology exams on April 6, 2021 ($124.60 + $124.60 + $75.80 = $325).  Tissue pathology exams fall within 
the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 copayment for tissue pathology exams on 
April 6, 2021. 
 
We also decided that the Plan does not have to waive the copayment for lab services provided on August 
4, 2021. 
 
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 $40 
copayment for lab services. 
 
You have been asked to pay a $40 copayment for lab services on August 4, 2021 ($31.39 + $8.61 = $40). Lab 
services fall within the Outpatient Diagnostic Tests and Therapeutic Services 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 waive the copayment for lab services on August 4, 2021. 
 
We also decided that the Plan does not have to waive the cost share for Part B drugs and administration 
provided on April 6, 2021, and August 4, 2021. 
 
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 30%   
for Part B drugs and administration.  
 
You have been asked to pay a total of $1,825.19, which is less than 30% for Part B drugs and administration 
received on April 6, 2021, and August 4, 2021. 
 
Date of Service Code Allowed Amount Coinsurance 
April 6, 2021 J0690 $44.10 $13.23 
April 6, 2021 J1100 $0.80 $0.24 
April 6, 2021 J2405 $0.51 $0.15 
April 6, 2021 J2704 $27.66 $8.30 
April 6, 2021 J3010 $11.65 $3.49 
Total  $25.41 
 
August 4, 2021 96367 $169.84 $50.95 
August 4, 2021 96372 $84.91 $25.47 
August 4, 2021 96413 $510.42 $153.13 
August 4, 2021 96417 $509.50 $152.85 
August 4, 2021 J1100 $0.76 $0.23 
August 4, 2021 J2405 $2.78 $0.83 
August 4, 2021 J2505 $4,747.10 $1,416.32 
Total  $1, 799.78 
 
Grand Total  $1,825.19 
 
Part B drugs and administration fall within the Medicare Part B Prescription Drug 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 coinsurance for Part B drugs and administration provided on April 6, 2021, and 
August 4, 2021. 
 
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.