Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visits, the laboratory 
services, and the chemotherapy injections provided on October 21, 2022, to November 14, 2022. 
 
You asked the Plan to waive the cost share for the specialist office visits, the laboratory services, and the 
injections. You say that you have met your maximum out-of-pocket amount. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
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 there is a $500 deductible which applies to the out-of-network office visits, lab 
services and injections. Your contract with the Plan also clearly says that you must pay 40% coinsurance, after 
your $500 plan deductible, for out-of-network chemotherapy drugs. 
 
The record shows you maximum out-of-pocket amount only applies to in-network services. You have been 
asked to pay $133.01 towards your deductible for each office visit provided on October 21, 2022, and 
November 11, 2022. The items or services you asked the Plan to waive the cost share for fall within the 
physician/practitioner services, including doctors office visits benefit category.  You have also been asked to 
pay $7.77 towards your deductible for each lab service provided on October 21, 2022, and November 11, 2022. 
The items or services you asked the Plan to waive the cost share for fall within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. You have also been asked to pay $218.44, which 
satisfies the deductible for an injection provided on November 14, 2022. The remaining allowed amount is 
$1,532.56 ($1,751 allowed amount - $218.44 deductible = $1,532.56). The item or service you asked the Plan 
to waive the cost share for falls within the Medicare Part B prescription drugs benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to 
physician/practitioner services, including doctors office visits, outpatient diagnostic tests and therapeutic 
services and supplies, and Medicare Part B prescription drugs. This cost sharing is a contractual obligation that 
had not been met at the time the specialist office visits, the laboratory services, and the injections was received 
on October 21, 2022, to November 14, 2022.  
 
You have been asked to pay $613.02, which is 40% coinsurance of the remaining allowed amount for an 
injection provided on November 14, 2022 ($1,532.56 remaining allowed amount x 40% = $613.02).  You have 
also been asked to pay $27.78, which is 40% coinsurance for a chemotherapy administration provided on 
November 14, 2022 ($69.46 allowed amount x 40% = $27.78). You have also been asked to pay $12.15, which 
is 40% coinsurance of the allowed amount for a chemo administration provided on November 14, 2022 ($30.37 
x 40% = $12.15). You have also been asked to pay $2,147.05, which is 20% coinsurance of the allowed 
amount for the pembrolizumab injection ($10,910 allowed amount x 20% coinsurance = $2,147.05). These 
items/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 cost share for the specialist office visits, the laboratory services, and the 
chemotherapy injections provided on October 21, 2022, to November 14, 2022.