Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for all the items/services provided from June 6, 
2022, to June 7, 2022. 
 
You asked the Plan to reduce the cost share for all the items/services. You say that you thought this would be 
charged as an inpatient stay. 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 20% 
coinsurance for Medicare Part B drugs. Your contract with the Plan also clearly says that you must pay 20% 
coinsurance for medical supplies. Your contract with the Plan also clearly says that you must pay a $15 
copayment for laboratory tests. Your contract with the Plan also clearly says that you must pay a $15 
copayment for x-rays. Your contract with the Plan also clearly says that you must pay a $275 copayment for 
outpatient surgery provided at an outpatient hospital facility. Your contract with the Plan also clearly says that 
you must pay a $20 copayment for each physical therapy visit. 
 
You have been asked to pay 20% coinsurance for each drug injection. This item/service falls within the 
Medicare Part B drugs benefit category. You have also been asked to pay 20% coinsurance for each medical 
supply. You have also been asked to pay up to a $15 copayment for each laboratory test. You have also been 
asked to pay up to a $15 copayment for each x-ray. These items/services fall within the outpatient diagnostic 
tests and therapeutic services benefit category. You have also been asked to pay up to a $275 copayment for the 
outpatient surgery. This item/service falls within the outpatient surgery benefit category. You have also been 
asked to pay up to a $20 copayment for the physical therapy visit. This item/service falls within the outpatient 
rehabilitation services benefit category. 
 
Date of Service Benefit Category Allowed 
Amount 
Copayment Coinsurance 
June 6, 2022 Medicare Part B drugs $113.93 - $22.79 
June 6, 2022 Outpatient diagnostic 
tests and therapeutic 
services 
$827.12 - $165.42 
June 6, 2022 Outpatient diagnostic 
tests and therapeutic 
services 
$553.28 - $110.66 
June 6, 2022 Outpatient diagnostic 
tests and therapeutic 
services 
$48.72 - $9.74 
June 6, 2022 Outpatient diagnostic 
tests and therapeutic 
services 
$696.64 - $139.33 
June 6, 2022 Outpatient diagnostic 
tests and therapeutic 
services 
$10,668 - $2,133.60 
June 6, 2022 Outpatient diagnostic 
tests and therapeutic 
services 
$6.72 - $6.72 
June 6, 2022 Outpatient diagnostic 
tests and therapeutic 
services 
$213.36 $15 - 
June 6, 2022 Outpatient surgery $8,006.32 $253.28 - June 6, 2022 Medicare Part B drugs $245.01 - $49 
June 6, 2022 Medicare Part B drugs $61.62 - $12.32 
June 6, 2022 Medicare Part B drugs $27.85 - $5.57 
June 6, 2022 Medicare Part B drugs $33.30 - $6.66 
June 6, 2022 Medicare Part B drugs $14.63 - $2.93 
June 6, 2022 Medicare Part B drugs $40.57 - $8.11 
June 6, 2022 Medicare Part B drugs $19.87 - $3.97 
June 6, 2022 Medicare Part B drugs $24.91 - $4.98 
June 6, 2022 Medicare Part B drugs $63.54 - $12.71 
June 6, 2022 Medicare Part B drugs $85.85 - $17.17 
June 6, 2022 Medicare Part B drugs $25.87 - $5.17 
June 6, 2022 Medicare Part B drugs $14.31 - $2.86 
June 6, 2022 Medicare Part B drugs $42.92 - $8.58 
June 6, 2022 Medicare Part B drugs $42.92 - $8.58 
June 7, 2022 Medicare Part B drugs $5.67 - $1.13 
June 7, 2022 Medicare Part B drugs $153.44 - $30.69 
June 7, 2022 Outpatient diagnostic 
tests and therapeutic 
services 
$31.36 - $6.27 
June 7, 2022 Outpatient diagnostic 
tests and therapeutic 
services 
$14.56 - $14.56 
June 7, 2022 Outpatient diagnostic 
tests and therapeutic 
services 
$17.92 - $0.44 
June 7, 2022 Outpatient rehabilitation 
services 
$79.52 $5 - 
June 7, 2022 Outpatient diagnostic 
tests and therapeutic 
services 
$86.24 - $17.25 
June 7, 2022 Medicare Part B drugs $16.65 - $3.33 
June 7, 2022 Medicare Part B drugs $6.81 - $1.36 
Total $3,085.18 
 
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 all the items/services provided from June 6, 2022, to June 7, 
2022.