Appeal type: Outpatient Therapies
Decision: Partially Favorable

You asked the Plan to pay for and waive the cost-sharing foroutpatient rehabilitation services. You say that you are requesting additional coverage and the balance to be paid by the Plan.The Plan says that the cost-sharing amounts you are being charged are correct, and the denial of payment for physical therapy is correct because you have exceeded the benefit limit for physical therapy in 2020.We decided that the Planhas to waive the coinsurance for outpatient rehabilitation services provided on April 23, 2020.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 enrollees must pay $25 copayment for each physical therapy visit. The Plan says you must pay $12.38 coinsurance in addition to the $25 copayment you have already been asked to pay for the physical therapy visit provided on April 23, 2020, which would result in a cost-sharing obligation of $37.38 for this visit. Based on the Plan contract, however, you cannot be asked to pay more than $25 copayment for each physical therapy visit. Therefore, we decided that the Plan has to pay for and waive the cost-sharing foroutpatient rehabilitation services. We decided that the Plan has to pay for outpatient rehabilitation services which the Plan denied from April 23, 2020, to July 21, 2020.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is providedthat the services will not be covered. The Plan follows these rules.These services were performed by an in-network provider. The file does not show that the Plan provided prior notice that these physical therapy services would not be covered. The Plan issued a denial notice on July 23, 2020; however, this authorization denial cannot be retroactively applied to services that had already been performed. Under Medicare rules, this means physical therapy is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the physical therapy services which it had denied from April 23, 2020, to July 21, 2020.We also decided that the Plandoes not have to waive the cost-sharing foroutpatient rehabilitation services.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 $25 copayment for each physical therapyvisit.For some of the dates of service, you have been asked to pay less than the copayment amount for physical therapy. A summary of your cost-sharing benefits is shown on the following page:Your total cost-sharing responsibility is therefore $120.71. Therefore, we decided that the Plan does not have to waive the cost-sharing foroutpatient rehabilitation services.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.