Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the radiation therapy and imaging services rendered on January 4, 2021 to January 8, 2021.
You asked the Plan to waive the copayments for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the copayments were 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 $60 copayment per visit for radiation therapy and a $250 copayment per visit for all other outpatient diagnostic and therapeutic services, such as CT scans.
Review of the file shows that you received radiation therapy with CT guidance on January 4, 2021. You have been asked to pay a $60 copayment for the radiation therapy. These services fall within the radiation therapy benefit category. Per the contract with the Plan, there is a $250 copayment per visit for all other outpatient diagnostic and therapeutic services, such as CT scans. However, the Medicare allowed amount for the CT scan was $83.99. Given that the allowed amount was less than the $250 copayment, you have been asked to pay $83.99 for the CT scan. 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 radiation therapy with CT guidance on January 5, 2021. You have been asked to pay a $60 copayment for the radiation therapy. These services fall within the radiation therapy benefit category. Per the contract with the Plan, there is a $250 copayment per visit for all other outpatient diagnostic and therapeutic services, such as CT scans. However, the Medicare allowed amount for the CT scan was $83.99. Given that the allowed amount was less than the $250 copayment, you have been asked to pay $83.99 for the CT scan. 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 radiation therapy with CT guidance on January 6, 2021. Per the contract with the Plan, there is a $60 copayment for radiation therapy. However, the Medicare allowed amount for these services was $39.24. Given that the allowed amount was less than the $60 copayment, you have been asked ot pay $39.24 for the radiation therapy. Per the contract with the Plan, there is a $250 copayment per visit for all other outpatient diagnostic and therapeutic services, such as CT scans. However, the Medicare allowed amount for the CT scan was $20.76. Given that the allowed amount was less than the $250 copayment, you have been asked to pay $20.76 for the CT scan. 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 radiation therapy with CT guidance on January 7, 2021. You have been asked to pay a $60 copayment for the radiation therapy. These services fall within the radiation therapy benefit category. Per the contract with the Plan, there is a $250 copayment per visit for all other outpatient diagnostic and therapeutic services, such as CT scans. However, the Medicare allowed amount for the CT scan was $83.99. Given that the allowed amount was less than the $250 copayment, you have been asked to pay $83.99 for the CT scan. 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 radiation therapy with CT guidance on January 8, 2021. You have been asked to pay a $60 copayment for the radiation therapy. These services fall within the radiation therapy benefit category. Per the contract with the Plan, there is a $250 copayment per visit for all other outpatient diagnostic and therapeutic services, such as CT scans. However, the Medicare allowed amount for the CT scan was $83.99. Given that the allowed amount was less than the $250 copayment, you have been asked to pay $83.99 for the CT scan. 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 $635.96. 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 radiation therapy and imaging services rendered on January 4, 2021 to January 8, 2021.