Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for  a specialist office visit provided on October 27, 
2022. We also decided that the Plan does not have to waive the cost share for  an injection administration, and 
an injection drug provided on December 14, 2022.  
 
You asked the Plan to waive the cost share for  a specialist office visit provided on October 27, 2022, and an 
injection administration, and a triamcinolone injection provided on December 14, 2022. You say that you 
should not be held responsible as the Plan took months to reprocess a claim. The Plan says that this cost sharing 
was charged correctly. 
 
We decided that the Plan has to waive the cost share for  a specialist office visit provided on October 27, 
2022.  
 
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 has not provided an Evidence of Coverage showing how the cost-
sharing was applied for this service. Therefore, we decided that the Plan has to waive the copayment for a 
specialist office visit provided on October 27, 2022.  
 
We also decided that the Plan does not have to waive the cost share for  an injection administration, and 
an injection drug. 
 
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 $30 
copayment for an injection administration. Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each Medicare-covered Part B drugs.  
 
You have been asked to pay a $30 copayment for the injection administration provided on December 14, 2022. 
This item/service falls 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 an injection administration provided on 
December 14, 2022.  
 
You have also been asked to pay a $1.71, which is 20% coinsurance of the allowed amount for the injection 
drug ($8.56 allowed amount x 20% = $1.71). This item/service falls within the Medicare Part B prescription 
drugs 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 an injection drug provided on 
December 14, 2022. 
 
 
 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.