Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost share for the cardiac catheterization (0480), the catheterization (93656 and 93657), and the basic imaging (93622 and 76000). We decided that the Plan does not have to waive the cost share for the Part B drugs (0250), the medical supplies (0272 and 0278), the CT scan (0350), and the diagnostic procedures (93613 and 92960).
You asked the Plan to waive the copayment for the cardiac catheterization (0480), the catheterization (93656 and 93657), the basic imaging (93622 and 76000), the Part B drugs (0250), the medical supplies (0272 and 0278), the CT scan (0350), and the diagnostic procedures (93613 and 92960). You say that you should only be charged a $300 copayment for the cardiac ablation procedure. The Plan says that you have been asked to pay the correct cost-sharing amount.
We decided that the Plan has to reduce the cost share for the cardiac catheterization (0480), the catheterization (93656 and 93657), and the basic imaging services (93622 and 76000).
The record shows the cardiac catheterization (0480) is considered a surgical procedure at an outpatient hospital. The record shows the catheterization (93656 and 93657) was billed by the physician and is considered a physician service. The record shows current procedural terminology (CPT) codes 93622 and 76000 are considered basic imaging services.
The Plan says that you must pay $2,370.28 for the cardiac catheterization (0480), $368.79 for the catheterization (93656 and 93657), and $36.08 for the basic imaging services. ($2,370.28 + $368.79 + $36.08 = $2,775.15).
Based on the plan contract, however, you cannot be asked to pay more than a $300 copayment for the cardiac catheterization (0480), a $50 copayment for the catherization (93656 and 93657), and a $20 copayment for the basic imaging services. ($300 + $50 + $20 = $370). Therefore, we decided that the Plan has to reduce the total cost share from $2,775.15 to $370.
We also decided that the Plan does not have to waive the cost share for the Part B drugs (0250), the medical supplies (0272 and 0278), the CT scan (0350), and the diagnostic procedures (93613 and 92960).
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 20% coinsurance for the Part B drugs (0250), 20% coinsurance for the medical supplies (0272 and 0278), a $175 copayment for the CT scan (0350), and 20% coinsurance for the diagnostic procedures (93613 and 92960). See chart below.
Date of Service Service Allowed Amount Coinsurance Member Liability December 29, 2020 Part B drug (0250) $297.38 20% $59.48
December 29, 2020
Part B drug (0250
$31.94
20%
$6.39 December 29, 2020 Medical supplies (0272) $3,692.90 20% $738.58
December 29, 2020
Medical supplies (0272)
$5,238.24
20%
$1,047.65 December 29, 2020 Medical supplies (0272) $3,089.21 20% $617.84
December 29, 2020
Medical supplies (0272)
$277.49
20%
$55.50 December 29, 2020 Medical supplies (0272) $215.55 20% $43.11
December 29, 2020
Medical supplies (0272)
$1,005.49
20%
$201.10 December 29, 2020 Medical supplies (0272) $118.47 20% $23.69
December 29, 2020
Medical supplies (0272
$2,068.26
20%
$413.65 December 29, 2020 CT scan (0350) $449.99 $175 $175
December 29, 2020
Diagnostic procedure (93613)
$353.61
20%
$70.72 December 29, 2020 Diagnostic procedure (92960) $125.27 20% $25.05
Total
$3,477.76
Therefore, we decided that the Plan does not have to waive the cost share for the Part B drugs (0250), the medical supplies (0272 and 0278), the CT scan (0350), and the diagnostic procedures (93613 and 92960).