Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible and copayment for a diagnostic mammography of both breasts (77066) and a biopsy of both breasts including placement of a locating device using X-ray with needle guidance (19081) provided on June 9, 2021.  You asked the Plan to waive the deductible and copayment for a bilateral diagnostic mammogram and breast biopsy. You say that you should not have to pay for the biopsy. You say a previous appointment identified a lymph node containing calcifications but the lymph node that underwent biopsy on June 9, 2021, was not the previously identified node. You say you should not have to pay for a biopsy of nothing. The Plan denied your request. The Plan says the cost-sharing was applied correctly. The Plan states the claim was processed with a deductible and a copayment. The Plan further confirmed your claim satisfied the annual $750 deductible.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible which must be met before the Plan will pay a share of the costs for Outpatient Hospital services. Your contract also says after the deductible is met, there is a $125 copayment for each outpatient surgery and a $10 copayment for diagnostic lab services.  The item or service you asked the Plan to waive the deductible for falls within the Outpatient Hospital benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to diagnostic procedures and tests involving basic or advanced diagnostic imaging services. This cost sharing is a contractual obligation that had been met after the bilateral breast biopsies were received on June 9, 2021.   You have been asked to pay a total cost-share of $240.54 for a bilateral diagnostic mammogram and breast biopsy, which fall within the Outpatient Hospital benefit category. The Plan allowed the provider to charge $803.49 for the biopsies. You were only charged $230.54, at which point, your annual deductible had been met. The Plan began to pay a share of the costs for the remainder of the claim.   $230.54 (applied to deductible) + $10 copayment (for diagnostic mammogram) = $240.54  Since the deductible was not met prior to receiving the biopsies, the $125 copayment for outpatient surgery does not apply. You have been asked to pay a lesser amount. Therefore, we decided that the Plan does not have to waive the deductible and copayment for a diagnostic mammography of both breasts (77066) and a biopsy of both breasts including placement of a locating device using X-ray with needle guidance (19081) provided on June 9, 2021.   Your complaint about potentially being charged for surgery of an improper location 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. The Plan states quality of care or service concerns go through a comprehensive evaluation process, but the process does not include waiving deductibles or copayments for services rendered, regardless of the outcome of that evaluation. The Plan reported your concerns were addressed in a separate letter sent to you on September 14, 2021. Please contact the Plan for more information.