Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost sharing amounts for the materials for home INR monitoring. 
We decided that the Plan does not have to waive the cost sharing amounts for the anticoagulant management.  
 You asked the Plan to waive the cost sharing amounts for the anticoagulant management for a patient taking 
warfarin (93793) and provision of test materials and equipment for home international normalized ratio (INR) 
monitoring (G0249) provided from June 9, 2022, to February 17, 2023. You say that your doctor appointments 
get expensive as you require them at least every two weeks. You also say that you do not understand what you 
owe as you receive conflicting information. The Plan denied your request. The Plan says the cost sharing was 
charged correctly. 
 
We decided that the Plan has to waive the cost sharing amounts for the materials for home INR 
monitoring.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). 
 
You have been asked to pay a $10 for the materials for home INR monitoring, per day. The Schedule of Cost 
Sharing does not specify what cost share the use of the home INR monitor would cost. Based on the type of 
service, you would reasonably expect the services to be covered either as a DME (durable medical equipment) 
item or laboratory testing, both of which carry $0 copayments. As such, the Plan has not met its obligation to 
clearly and accurately describe the cost sharing for this service. Although the Plan is correct that these services 
are paid by Medicare under the Physician Fee Schedule, this fact is not sufficient to support that a physician 
service copayment would apply. Therefore, we decided that the Plan has to waive the cost sharing amounts for 
the materials for home INR monitoring for the dates of service at issue in this case. 
 
We also decided that the Plan does not have to waive the cost sharing amounts for the anticoagulant 
management. 
 
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 $10 
copayment for Physician specialist services.  
 
You have been asked to pay a $10 copayment for each anticoagulation management visit. These services fall 
within the Physician specialist services 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 
amounts for the anticoagulant management. 
 
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. 
 
Your complaint about the claims being denied and reprocessed is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.