Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the deductible and reduce the cost-sharing to $15 for a CTA scan of the 
neck (70498) performed on June 25, 2020. We also decided that the Plan has to hold you harmless for a CT 
scan of the thorax (71260), a CTA scan of the head (70496), and an injection of contrast material (Q9967) 
performed on June 25, 2020. 
 
You asked the Plan to waive the deductible and reduce the cost-sharing to $15 for a CTA scan of the neck as 
well as to hold you harmless for a CT scan of the thorax, a CTA scan of the head, and an injection of contrast 
material. You say that you had no knowledge that both the referring provider and the hospital failed to get the 
services in question pre-approved. The Plan denied your request. The Plan says that the correct cost-sharing 
was applied for a CTA scan of the neck. The Plan also says that rules for payment for a CT scan of the thorax, 
a CTA scan of the head, and an injection of contrast material have not been met. 
 
Regarding the request to waive the deductible and reduce the cost-sharing for a CTA scan of the neck: 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 a $15 copayment for each Medicare-covered diagnostic imaging service 
received from an in-network provider.  
 
The Plan says you must pay an out-of-network deductible plus 20% coinsurance for a CTA scan of the neck. 
The case record reflects that this service was received from an in-network provider. Based on the Plan contract, 
you cannot be asked to pay more than a $15 copayment for a CTA scan of the neck received from an in-
network provider. Therefore, we decided that the Plan has to waive the deductible and reduce the cost-sharing 
to $15 for a CTA scan of the neck (70498) performed on June 25, 2020. 
 
Regarding the request to hold you harmless for a CT scan of the thorax, a CTA scan of the head, and an 
injection of contrast material: 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 provided that the 
services will not be covered. The Plan follows these rules. 
 
You were referred for a CT scan of the thorax, a CTA scan of the head, and an injection of contrast material by 
a contract provider. The file does not show that the Plan provided notice that a CT scan of the thorax, a CTA 
scan of the head, and an injection of contrast material would not be covered. Under Medicare rules, this means 
a CT scan of the thorax, a CTA scan of the head, and an injection of contrast material is considered approved 
by the Plan. Therefore, we decided that the Plan has to hold you harmless for a CT scan of the thorax (71260), 
a CTA scan of the head (70496), and an injection of contrast material (Q9967) performed on June 25, 2020. 
 
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.