Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the retina imaging provided from May 9, 
2022, to November 22, 2022, the specialist office visits provided from May 9, 2022, to December 5, 2022, the 
injection drugs provided from May 9, 2022, to October 28, 2022, and the injection administration provided 
from June 6, 2022, to October 28, 2022. 
 
You asked the Plan to waive the cost share for the retina imaging, the specialist office visits, the injection 
drugs, and the injection administration. You say that you were told that you would not have a cost share. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65.00 
copay for each covered diagnostic procedure or test at a network doctor's office. Your contract with the Plan 
also clearly says that you must pay a $35.00 copay for each covered specialist office visit. Your contract with 
the Plan also clearly says that you must pay a $35.00 copay for each Medicare-covered exam to treat an eye 
condition. Your contract with the Plan also clearly says that you must pay 20% coinsurance for chemotherapy 
and other drugs covered by Medicare Part B. 
 
You have been asked to pay $40.96, which is less than the standard copayment for each imaging of retina 
provided on May, 9, 2022, June 6, 2022, July 11, 2022, August 8, 2022, September 12, 2022, October 10, 
2022, October 24, 2022, and November 11, 2022.These items/services fall within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. You have also been asked to pay a $35 copayment for 
each specialist office visit provided on May 9, 2022, August 8, 2022, October 24, 2022, November 11, 2022, 
and December 5, 2022. These items/services fall within the physician/practitioner services, including doctor's 
office visits benefit category. You have also been asked to pay $35 for each injection administration provided 
on June 6, 2022, July 11, 2022, September 12, 2022, October 10, 2022, and October 28, 2022. These 
items/services fall within the vision care benefit category. You have also been asked to pay 20% coinsurance 
for the injection drugs. These items/services fall within the Medicare Part B prescription drugs benefit 
category.   
Date of Service Code Allowed Amount 20% Coinsurance 
May 9, 2022 J3590 $69.23 $13.85 
June 6, 2022 J9035 $69.49 $13.90 
July 11, 2022 J9035 $69.23 $13.85 
August 8, 2022 J0178 $1,825.78 $365.16 
September 12, 2022 J0178 $1,825.78 $365.16 
October 10, 2022 C9257 $50.00 $10.00 
October 28, 2022 J3301 $5.16 $1.03 
 
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 retina imaging provided from May 9, 2022, to November 
22, 2022, the specialist office visits provided from May 9, 2022, to December 5, 2022, the injection drugs 
provided from May 9, 2022, to October 28, 2022, and the injection administration provided from June 6, 2022, 
to October 28, 2022.