Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the non-invasive extremity study, the duplex scan, and the Carotid doppler test you had on December 21, 2020, and the pelvic ultrasound, transthoracic echocardiography, and duplex scan you had on December 28, 2020.
You asked the Plan to waive the copayments for the diagnostic services. You say that you do not agree with these very high copayments. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan states that for the pelvic ultrasound and the non-invasive extremity study, the allowed amount for each ($86.70 and $99.22, respectively) is less than your copayment obligation, so you are responsible for the full allowed amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles andWe decided that the Plan does not have to waive the copayments for the non-invasive extremity study, the duplex scan, and the Carotid doppler test you had on December 21, 2020, and the pelvic ultrasound, transthoracic echocardiography, and duplex scan you had on December 28, 2020.
You asked the Plan to waive the copayments for the diagnostic services. You say that you do not agree with these very high copayments. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan states that for the pelvic ultrasound and the non-invasive extremity study, the allowed amount for each ($86.70 and $99.22, respectively) is less than your copayment obligation, so you are responsible for the full allowed amount.
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 $110 copayment for each radiological diagnostic service.
You have been asked to pay a $110 copayment for each of the diagnostic services you received. All of these tests fall within the radiological diagnostic service 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 copayments for the non-invasive extremity study, the duplex scan, and the Carotid doppler test you had on December 21, 2020, and the pelvic ultrasound, transthoracic echocardiography, and duplex scan you had on December 28, 2020. coinsurance). Your contract with the Plan clearly says that you must pay a $110 copayment for each radiological diagnostic service.
You have been asked to pay a $110 copayment for each of the diagnostic services you received. All of these tests fall within the radiological diagnostic service 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 copayments for the non-invasive extremity study, the duplex scan, and the Carotid doppler test you had on December 21, 2020, and the pelvic ultrasound, transthoracic echocardiography, and duplex scan you had on December 28, 2020.