Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for multiple items/services received on September 26, 2020, to January 18, 2021.
You asked the Plan to waive the cost-sharing for multiple items/services. You say that you did not receive effective treatment at the hospital and therefore feel that someone at the hospital should be responsible for all these and upcoming bills. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 contracts with the Plan for 2020 and 2021 clearly say that you must pay 20% coinsurance for Medicare-covered durable medical equipment and related supplies. You have been asked to pay $10.01, or 20% of the Medicare-allowed amount of $50.05, for underarm crutches received on September 26, 2020; to pay $3.84, or 20% of the Medicare-allowed amount of $19.20, for wound-care supplies received on November 6, 2020; to pay $3.00, or 20% of the Medicare-allowed amount of $15.00, for wound-care supplies received on November 16, 2020; to pay $2.56, or 20% of the Medicare-allowed amount of $12.80, for wound-care supplies received on December 10, 2020; and to pay $51.68, or 20% of the Medicare-allowed amount of $258.40, for wound-care supplies received on January 8, 2021. Underarm crutches and wound-care supplies fall within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Your contract with the Plan for 2020 clearly says that you must pay a $35 copayment per day, per provider, for Medicare-covered X-ray services. You have been asked to pay a $30.96 copayment per date of service for X-rays received on September 28 and October 20, 2020. X-rays fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay less than or equal to the correct amount based on your contract with the Plan. Your contract with the Plan for 2020 clearly says that you must pay a $250 copayment for each one-way Medicare-covered ambulance transport. You have been asked to pay a $250 copayment for ambulance services received on October 6, 2020. This means that you have been asked to pay the correct amount based on your contract with the Plan. Your contract with the Plan for 2020 clearly says that you must pay a $90 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $90 copayment per visit for two emergency room visits on October 6, 2020. Emergency room visits fall within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Your contract with the Plan for 2020 clearly says that you must pay a $50 copayment for each Medicare-covered visit with a specialist. You have been asked to pay a $44.22 copayment for a specialist office visit on December 29, 2020. A specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay less than or equal to the correct amount based on your contract with the Plan. Your contract with the Plan for 2020 clearly says that you must pay a $20 copayment per day, per provider, for Medicare-covered lab services. You have been asked to pay a $20 copayment for labs performed on December 29, 2020. Labs 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. Your contract with the Plan for 2021 clearly says that you must pay a $45 copayment for each Medicare-covered visit with a specialist. You have been asked to pay a $45 copayment for a specialist office visit on January 7, 2021. A specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Your contract with the Plan for 2021 clearly says that you must pay a $225 copayment for Medicare-covered diagnostic radiology services. You have been asked to pay a $35 copayment for a radiopharmaceutical localization of tumor performed on January 18, 2021. A radiopharmaceutical localization of tumor falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you
have been asked to pay less than or equal to 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 multiple items/services received on September 26, 2020, to January 18, 2021.
Your complaint about receiving ineffective treatment at the hospital 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.