Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the IV infusion, the saline solution infusion, 
and the bezlotoxumab injections provided on January 23, 2023. 
 You asked the Plan to waive the cost share for the IV infusion, the saline solution infusion, and the injections. 
You say that the previous visits were fully covered. 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 $250 deductible which applies to outpatient surgery and other medical 
services provided at hospital outpatient facilities and Medicare Part B prescription drugs. Your contract with 
the Plan also clearly says that you must pay 20% coinsurance for Medicare-covered surgery or other services at 
an outpatient hospital. Your contract with the Plan also clearly says that you must pay 20% coinsurance for 
each Medicare-covered Part B drug. 
 
You have been asked to pay $170 towards the deductible for the IV infusion. The item or service you asked the 
Plan to waive the cost share for falls within the outpatient surgery and other medical services provided at 
hospital outpatient facilities benefit category. You have also been asked to pay $80, which satisfies the 
deductible for the injection (J0565), the remaining allowed amount for the injection (J0565) is $2,027.83 
($2,107.83 allowed amount - $80 deductible = $2,027.83). 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 $250 deductible which applies to outpatient 
surgery and other medical services provided at hospital outpatient facilities and Medicare Part B prescription 
drugs. This cost sharing is a contractual obligation that had not been met at the time the IV infusion, the 
injection (J0565) was received on January 23, 2023. 
 
You have also been asked to pay $405.57, which is 20% coinsurance of the remaining allowed amount for the 
injection (J0565) ($2,027.83 remaining allowed amount x 20% = $405.57). You have also been asked to pay 
$253.35, which is 20% coinsurance of the allowed amount for the injection (J0565-JW) ($1,266.74 allowed 
amount x 20% = $ 253.35). These items/services fall within the Medicare Part B prescription drugs benefit 
category. You have also been asked to pay $2.49, which is 20% coinsurance of the allowed amount for the 
saline solution infusion ($12.44 allowed amount x 20% = $2.49). This item/service falls within the outpatient 
surgery and other medical services provided at hospital outpatient facilities 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 IV infusion, the saline solution infusion, and the bezlotoxumab 
injections provided on January 23, 2023.