Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost sharing for the infusion services. We decided that the Plan 
does not have to waive the cost sharing for the catheter insertion, and the infusion services.  
 
You asked the Plan to waive the cost sharing for the catheter insertion provided by an in-network provider on 
January 30, 2023, and the infusion services provided by an in-network provider from January 31, 2023, to 
March 14, 2023. You say that you do not understand why these services are not covered. The Plan says that this 
cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the cost sharing for the infusion services. 
 
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 says that you must pay a 20% 
coinsurance for each in-network Medicare-covered Part B drug obtained in a providers office or outpatient 
setting. The Plan says you must pay a $2,604.40 coinsurance, which is more than a 20% coinsurance for the in-
network infusion services. Based on the Plan contract, however, you cannot be asked to pay more than a 20% 
coinsurance for Medicare Part B covered drugs. Therefore, we decided that the Plan has to reduce the cost 
sharing for the infusion services.  
 
Date of Service Allowed Amount Incorrect 
Coinsurance 
Correct 
Coinsurance 
January 31, 2023 $255.20 $51.87 $51.04 
February 1, 2023 $294.66 $59.89 $58.93 
February 2, 2023 $255.20 $51.87 $51.04 
February 3, 2023 $255.20 $51.87 $51.04 
February 4, 2023 $255.20 $51.87 $51.04 
February 5, 2023 $231.83 $47.12 $46.37 
February 6, 2023 $255.20 $51.87 $51.04 
February 7, 2023 $255.20 $51.87 $51.04 
February 8, 2023 $294.66 $59.89 $58.93 
February 9, 2023 $294.66 $59.89 $58.93 
February 10, 2023 $255.20 $51.87 $51.04 
February 11, 2023 $255.20 $51.87 $51.04 
February 12, 2023 $294.66 $59.89 $58.93 
February 13, 2023 $255.20 $51.87 $51.04 
February 14, 2023 $294.66 $59.89 $58.93 
February 15, 2023 $294.66 $59.89 $58.93 
February 16, 2023 $255.20 $51.87 $51.04 
February 17, 2023 $294.66 $59.89 $58.93 
February 18, 2023 $255.20 $51.87 $51.04 
February 20, 2023 $294.66 $59.89 $58.93 
February 21, 2023 $294.66 $59.89 $58.93 
February 22, 2023 $294.66 $59.89 $58.93 
February 23, 2023 $255.20 $51.87 $51.04 
February 24, 2023 $294.66 $59.89 $58.93 
February 25, 2023 $294.66 $59.89 $58.93 
February 26, 2023 $294.66 $59.89 $58.93 
February 27, 2023 $255.20 $51.87 $51.04 
February 28, 2023 $294.66 $59.89 $58.93 
March 1, 2023 $294.66 $59.89 $58.93  
 
 
 
 
 
 
 
 
 
 
 
 
We also decided that the Plan does not have to waive the cost sharing for the catheter insertion and the 
infusion services. 
 
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 $290 
copayment for each in-network Medicare-covered outpatient hospital facility visit, and a 20% coinsurance for 
in-network Medicare Part B covered drugs. 
 
You have been asked to pay a $290 copayment for the catheter insertion. This item/service falls within the 
outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. You are also being held responsible for a $2226.29 coinsurance for the infusion services. 
These items/services fall 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 cost sharing for the catheter insertion provided by an in-network provider on 
January 30, 2023, and the infusion services provided by an in-network provider from January 31, 2023, to 
March 14, 2023. 
 
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.