Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient hospital facility visits, laboratory services, a CT scan and does not have to waive the coinsurance for Medicare Part B drugs provided from April 14, 2020, to November 11, 2020.

You asked the Plan to waive the copayments for outpatient hospital facility visits, laboratory services, a CT scan and to waive the coinsurance for Medicare Part B drugs. You say that your oncologist verified that the services were covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $250 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. Your contract with the Plan also clearly says that you must pay a $10 copayment for laboratory services and a $100 copayment for radiological diagnostic services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 

You received outpatient hospital facility visits, laboratory services, a CT scan and does not have to waive the coinsurance for Medicare Part B drugs provided from April 14, 2020, to November 11, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.

Date(s) of Service
Service
Allowed Amount
Amount You Owe

4/14/2020
Outpatient Hospital Visit
$108.60
$108.60

5/1/2020 - 7/29/2020
Medicare Part B Drugs
$13,019
$2,603.80

6/10/2020
Outpatient Hospital Visit
$108.60
$108.60

6/16/2020
Laboratory Services
$10.56
$10

7/17/2020
CT Scan
$170.70
$100

7/22/2020
Outpatient Hospital Visit
$108.60
$108.60

8/5/2020 - 8/26/2020
Medicare Part B Drugs
$4,543.20
$908.64

9/23/2020
Laboratory Services
$7.77
$7.77

9/30/2020
Laboratory Services
$7.77
$7.77

10/8/2020
Medicare Part B Drugs
$11,113.92
$2,200.28

10/14/2020
Laboratory Services
$7.77
$7.77

11/11/2020
Laboratory Services
$7.77
$7.77

The total amount you owe is: $6,179.60. 

You have been asked to pay the total copayment amount of $6,179.60 for outpatient hospital facility visits, laboratory services, a CT scan and Medicare Part B drugs. Outpatient hospital facility visits fall within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. Laboratory services and a CT scan fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. Medicare Part B drugs fall 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 copayments for outpatient hospital facility visits, laboratory services, a CT scan and does not have to waive the coinsurance for Medicare Part B drugs provided from April 14, 2020, to November 11, 2020.