Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an interrogation device evaluation (93295) 
performed on April 6, 2020, a programming device evaluation (93284) performed on June 29 and July 13, 
2020, and a transthoracic echocardiography (93306)), a myocardial perfusion imaging procedure (78452)), a 
cardiovascular stress test (93015), a Regadenoson injection (J2785), a Technetium tc-99m tetrofosmin dose 
(A9502), and a Technetium tc-99m sestamibi dose (A9500) received on July 6, 2020. 
 
You asked the Plan to waive the cost-sharing for an interrogation device evaluation, a programming device 
evaluation, a transthoracic echocardiography, a myocardial perfusion imaging procedure, a cardiovascular 
stress test, a Regadenoson injection, a Technetium tc-99m tetrofosmin dose, and a Technetium tc-99m 
sestamibi dose. You say that you were advised that the Plan was waiving copayment charges due to the 
pandemic. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
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 $160 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays; a $30 copayment 
for Medicare-covered non-radiological diagnostic services; and 20% coinsurance for each Medicare-covered 
Part B drug and each Medicare-covered medical supply.  
 
You have been asked to pay a $160 copayment each for a transthoracic echocardiography and a myocardial 
perfusion imaging procedure and a $30 copayment each for an interrogation device evaluation, a cardiovascular 
stress test, and 2 programming device evaluations. You have also been asked to pay $47.50, or 20% of the 
Medicare-allowed amount of $237.48, for a Regadenoson injection; $22.22, or 20% of the Medicare-allowed 
amount of $111.10, for a Technetium tc-99m tetrofosmin dose; and $24.34, or 20% of the Medicare-allowed 
amount of $121.70, a Technetium tc-99m sestamibi dose. These charges are not eligible for the Plan?s cost-
sharing waiver except in situations where the services received are related to a COVID-19 diagnosis. An 
interrogation device evaluation, a programming device evaluation, a transthoracic echocardiography, a 
myocardial perfusion imaging procedure, a cardiovascular stress test, a Technetium tc-99m tetrofosmin dose, 
and a Technetium tc-99m sestamibi dose fall within the "Outpatient Diagnostic Tests and Therapeutic Services 
and Supplies" benefit category. A Regadenoson injection falls within the "Medicare Part B Prescription Drugs" 
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 cost-sharing for an interrogation device 
evaluation (93295) performed on April 6, 2020, a programming device evaluation (93284) performed on June 
29 and July 13, 2020, and a transthoracic echocardiography (93306)), a myocardial perfusion imaging 
procedure (78452)), a cardiovascular stress test (93015), a Regadenoson injection (J2785), a Technetium tc-
99m tetrofosmin dose (A9502), and a Technetium tc-99m sestamibi dose (A9500) received on July 6, 2020.  
 
Your complaint about not receiving information from your provider about your cost-sharing responsibility 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.