Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the intravitreal injections, the classified 
biologics, and the retina imaging services, and the specialist office visit provided from March 15, 2022, to 
November 28, 2022. 
 
You asked the Plan to reduce the cost share for the intravitreal injections, the classified biologics, and the retina 
imaging services, and the specialist office visit. You say that you disagree with the 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. Your 
contract with the Plan says that there is a $400 deductible which applies to outpatient surgery, including 
services provided at ambulatory surgical centers. Your contract with the Plan also clearly says that you must 
pay 2% of the approved amount for outpatient surgery. Your contract with the Plan also clearly says that you 
must pay 2% of the approved amount for Medicare Part B prescription drugs. Your contract with the Plan also 
clearly says that you must pay 2% of the approved amount for diagnostic tests. Your contract with the Plan also 
clearly says that you must pay a $20 copayment for medical office visits. 
 
You have been asked to pay $116.39 towards the $400 deductible for the intravitreal injection provided on 
March 15, 2022. You have also been asked to pay $4.18 towards the deductible for the intravitreal injection 
provided on June 28. 2022. The remaining allowed amount is $112.21 ($116.39 - $4.18 deductible = $112.21. 
The services you asked the Plan to reduce the cost share for falls within the outpatient surgery, including 
services provided at ambulatory surgical centers benefit category. You have also been asked to pay $41.54 
towards the deductible for each retina imaging provided on March 15, 2022, and June 28, 2022. The services 
you asked the Plan to reduce the cost share for falls within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. You have also been asked to pay $173 towards your deductible for the 
unclassified biologics provided on March 15, 2022. The service you asked the Plan to reduce 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 $400 deductible which applies to outpatient surgery, including 
services provided at ambulatory surgical centers. This cost sharing is a contractual obligation that had not been 
met at the time the intravitreal injections, the classified biologics, and the retina imaging services, and the 
specialist office visit was received on March 15, 2022, to November 28, 2022.  
 
You have also been asked to pay $2.24, which is 2% coinsurance of the allowed amount for the intravitreal 
injection provided on June 28, 2022 ($112.21 remaining allowed amount x 2% = $2.24). You have also been 
asked to pay $2.33, which is 2% coinsurance of the allowed amount for each intravitreal injection provided on 
September 12, 2022, and November 28, 2022 ($116.39 allowed amount x 2% = $2.33). These services fall 
within the outpatient surgery, including services provided at ambulatory surgical centers drugs benefit 
category. You have also been asked to pay $3.46, which is 2% coinsurance of the allowed amount for the 
unclassified biologics provided on June 28, 2022 ($173 allowed amount x 2% = $3.46). You have also been 
asked to pay $3.20, which is 2% coinsurance of the allowed amount for the unclassified biologics provided on 
November 28, 2022 ($160 allowed amount x 2% = $3.20). These services fall within the Medicare Part B 
prescription drugs benefit category. You have also been asked to pay $0.83, which is 2% coinsurance of the 
allowed amount for each retina imaging provided on September 12, 2022, and November 28, 2022. ($41.54 
allowed amount x 2% = $0.83). These 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. 
 You have also been asked to pay a $20 copayment for each office visit provided on March 15, 2023, and June 
28, 2022. These services fall within the physician/practitioner services, including doctors office visits 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 reduce the cost share for the intravitreal injections, the classified 
biologics, and the retina imaging services, and the specialist office visit provided from March 15, 2022, to 
November 28, 2022.