Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the office visits, the EKG, the IV therapy, 
and the medical equipment provided from December 6, 2022, to December 30, 2022. 
 You asked the Plan to waive the coinsurance for the office visits, the EKGs, the IV therapies and the medical 
equipment. You say that the services should be fully covered. 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 40% 
coinsurance for out-of-network Medicare Part B prescription drugs, out-of-network physician/practitioner 
services, including doctors office visits, out-of-network outpatient diagnostic tests and therapeutic services and 
supplies, and out-of-network durable medical equipment and related supplies.  
 
You have been asked to pay 40% coinsurance for each office visit. These items/services fall within the 
physician/practitioner services, including doctors office visits benefit category. You have also been asked to 
pay a 40% coinsurance for each EKG. These items/services fall within the outpatient diagnostic tests and 
therapeutic services and supplies benefit category. You have also been asked to pay a 40% coinsurance for 
each IV therapy. These items/services fall within the Medicare Part B prescription drugs benefit category. 
You have also been asked to pay a 40% coinsurance for each medical equipment. These items/services fall 
within the durable medical equipment and related supplies benefit category. 
 
Date of Service Item Allowed Amount 40% Coinsurance 
December 6, 2022 Office visit $72.55 $29.02 
December 26, 2022 Office visit $125.00 $50.00 
December 26, 2022 EKG $5.73 $2.29 
December 26, 2022 IV therapy $25.00 $10.00 
December 26, 2022 IV therapy $30.00 $12.00 
December 26, 2022 IV therapy $25.00 $10.00 
December 26, 2022 IV therapy $45.00 $18.00 
December 26, 2022 Prolonged care $10.29 $4.12 
December 26, 2022 Prolonged care $17.88 $7.15 
December 26, 2022 Medical equipment $12.69 $5.08 
December 27, 2022 Office visit $125.00 $50.00 
December 27, 2022 EKG $5.73 $2.29 
December 27, 2022 IV therapy $25.00 $10.00 
December 27, 2022 IV therapy $30.00 $12.00 
December 27, 2022 IV therapy $25.00 $10.00 
December 27, 2022 IV therapy $45.00 $18.00 
December 27, 2022 Prolonged care $187.14 $74.86 
December 27, 2022 Medical equipment $12.69 $5.08 
December 28, 2022 Office visit $125.00 $50.00 December 28, 2022 EKG $5.73 $2.29 
December 28, 2022 IV therapy $25.00 $10.00 
December 28, 2022 IV therapy $30.00 $12.00 
December 28, 2022 IV therapy $25.00 $10.00 
December 28, 2022 IV therapy $45.00 $18.00 
December 28, 2022 Prolonged care $10.29 $4.12 
December 28, 2022 Prolonged care $17.88 $7.15 
December 28, 2022 Medical equipment $12.69 $5.08 
December 29, 2022 Office visit $125.00 $50.00 
December 29, 2022 EKG $5.73 $2.29 
December 29, 2022 IV therapy $25.00 $10.00 
December 29, 2022 IV therapy $30.00 $12.00 
December 29, 2022 IV therapy $25.00 $10.00 
December 29, 2022 IV therapy $45.00 $18.00 
December 29, 2022 Prolonged care $10.29 $4.12 
December 29, 2022 Prolonged care $17.88 $7.15 
December 29, 2022 Medical equipment $12.69 $5.08 
December 30, 2022 EKG $5.73 $2.29 
December 30, 2022 IV therapy $25.00 $10.00 
December 30, 2022 IV therapy $30.00 $12.00 
December 30, 2022 IV therapy $25.00 $10.00 
December 30, 2022 IV therapy $45.00 $18.00 
December 30, 2022 Prolonged care $17.88 $7.15 
December 30, 2022 Medical equipment $12.69 $5.08 
 
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 coinsurance for the office visits, the electrocardiograms (EKG), the 
intravenous (IV) therapies, and the medical equipment provided from December 6, 2022, to December 30, 
2022.