Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost sharing for the services rendered on February 12, 2020. We 
decided that the Plan does not have to waive the cost sharing for the services rendered from February 24, 2020 
to May 19, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that the cost sharing is a financial 
hardship. The Plan says that the cost sharing was applied correctly. 
 
We decided that the Plan has to waive the cost sharing for the services rendered on February 12, 2020. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that a coinsurance of $515.40 was applied for services rendered 
on February 12, 2020. The Plan has not provided any documentation, such as an Explanation of Benefits 
(EOB) for this date of service to show what services were rendered. Without this documentation, it is not clear 
that the correct coinsurance was applied. Therefore, we decided that the Plan has to waive the cost sharing for 
the services rendered on February 12, 2020.  
 
We also decided that the Plan does not have to waive the cost sharing for the services rendered from 
February 24, 2020 to May 19, 2020. 
 
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 $40 
copayment for Medicare covered physical, occupational, and speech therapy visits, a 20% coinsurance for 
diagnostic radiology, a $275 copayment for each one-way Medicare covered ambulance trip, a 20% 
coinsurance for Medicare Part B prescription drugs, a $20 copayment for primary care physician services, a 
$50 copayment for specialty care services, and a 20% coinsurance for laboratory tests. 
 
Review of the file shows that you received physical therapy services for five dates of service from February 24, 
2020 to March 17, 2020. You have been asked to pay a $40 copayment per visit for these services, for a total of 
$200. These services fall within the Medicare covered physical, occupational, and speech therapy visits 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 a computed tomography angiography (CTA) scan of the abdomen and pelvis 
on April 28, 2020. You have been asked to pay a 20% coinsurance for these services, for a total of $80. These 
services fall within the diagnostic radiology 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 a one-way ambulance transport on April 28, 2020. You have been asked to 
pay a $275 copayment for these services. These services fall within the one-way Medicare covered ambulance 
trip 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 echocardiogram on May 5, 2020. You have been asked to pay a 20% 
coinsurance for these services, for a total of $50. These services fall within the diagnostic radiology 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 Part B drug injections on May 5, 2020. You have been asked to pay a 20% 
coinsurance for these services, for a total of $65.74. These services fall within the Medicare Part B drugs 
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 myocardial perfusion imaging (MPI) on May 5, 2020. You have been asked to 
pay a 20% coinsurance for these services, for a total of $91.96. These services fall within the diagnostic 
radiology 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 specialty physician services on May 12, 2020. You have been asked to pay a 
$50 copayment for these services. These services fall within the specialty care services 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 primary care physician services on May 19, 2020. You have been asked to pay 
a $20 copayment for these services. These services fall within the primary care physician services 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 laboratory services on May 19, 2020. You have been asked to pay a 20% 
coinsurance for these services, for a total of $6.31. These services fall within the laboratory 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 $839.01. 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 February 24, 2020 to May 19, 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.