Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the services rendered from January 28, 
2020 to March 17, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that the office doesn't help you and 
you do not want to pay the cost sharing. The Plan denied your request. The Plan says the cost sharing was 
applied 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 a $30 
copayment for services obtained from a specialist, a $160 copayment for each Medicare-covered radiological 
diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility, and a 
$20 copayment for Medicare-covered non-radiological diagnostic services. 
 
Review of the file shows that you received specialist services on January 28, 2020; February 26, 2020; and 
March 17, 2020. You have been asked to pay a $30 copayment per date of service for these services, for a total 
of $90. These services fall within the services obtained from a specialist benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. 
 
The file shows that you received an upper extremity study on February 12, 2020. Per the contract with the Plan, 
there is a $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, 
performed in a physician's office or at a free-standing facility. However, the Medicare allowed amount for 
these services was $85.78. Given that the allowed amount was less than the $160 copayment, you have been 
asked to pay $85.78 for these services. 
 
The file shows that you received autonomic nerve testing on February 12, 2020. Per the contract with the Plan, 
there is a $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, 
performed in a physician's office or at a free-standing facility. However, the Medicare allowed amount for 
these services was $87.04. Given that the allowed amount was less than the $160 copayment, you have been 
asked to pay $87.04 for these services. 
 
The file shows that you received an electroencephalogram (EEG) on February 21, 2020. You have been asked 
to pay a $20 copayment for these services. These services fall within the services obtained from the Medicare-
covered non-radiological diagnostic services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. 
 
The total amount you have been asked to pay for these services is $282.82. 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 the services rendered from January 28, 2020 to March 17, 2020.  
 
Your complaint about the provider 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.