Appeal type: Surgery
Decision: Partially Favorable

How we made our decision  1. We read all the papers in the file.2. We checked Medicare rules.3. We checked the contract with the Plan. 4. If required, we sent the file to a MAXIMUS Federal Services physician reviewer.To make our decision we read all the papers in the file very carefully. We used the Medicare rules. We looked to see if the Plan correctly followed Medicare rules and regulations.Medicare rules say that the Plan must give the member a subscriber agreement. It is a contract between the Plan and the member. It is usually called the "Evidence of Coverage" (EOC) or "Member Agreement." We read this contract carefully to see what the Plan is supposed to cover.The Plan sent additional information to us. This information was not received in the original case file from the Plan. Our decision was made using all of the information we received.Medicare rules The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. You can find this rule in the Medicare Claims Processing Manual, Chapter 4, Section 180.7.The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR 422.111(a) and (b).The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR 422.2.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $325 copayment per day for days 1-4 for inpatient hospital care. You can find this information on page 71 of the Plan's 2019 Evidence of Coverage.Explanation of decisionWe decided that the Plan has to reducethe cost forthe knee replacement. We decided that the Plan does not have to waive the copaymentforthe knee replacement. You asked the Plan to waive the cost forthe knee replacement. You say that you were advised prior to surgery that everything was taken care of. You say that you shouldn't be responsible.The Plan says that the claim was reprocessed to reflect outpatient services.
We decided that the Plan has to reduce the cost for the knee replacement. The Plan follows Medicare rules. Medicare rules say that a total knee replacement is on the inpatient only list.The Plan says that you must pay $1,394.04 for the knee replacement as an outpatient procedure. Based on the Plan contract, however, you cannot be asked to pay more than a $325 copayment for the knee replacement as an inpatient procedure. Therefore, we decided that the Plan has to reduce the cost forthe knee replacement. We also decided that the Plandoes not have to waive the copaymentforthe knee replacement.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 $325 copayment per day for days 1-4 for inpatient hospital care.The records show that you were admitted and discharged on May 28, 2019, which applies one inpatient day. Therefore, we decided that the Plan does not have to waive the $325 copaymentforthe knee replacement.If the Plan doesnot 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.