Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for lab test and outpatient dialysis on May 12, 
2022, to May 31, 2022. 
 
You asked the Plan to waive the cost sharing for lab test and outpatient dialysis. You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
 
 
 
 
 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 $15 
copayment for Medicare-covered labs and non-radiological diagnostic tests. Covered services include but are 
not limited to laboratory and diagnostic tests billed by the hospital. You must pay a 20% coinsurance for each 
Medicare-covered dialysis treatment performed as an outpatient service. Covered services include Outpatient 
dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in 
Chapter 3). 
 
On May 12, 2022, the provider billed in the amount of $1,794 and the allowed amount is $465.90. $465.90 x 
20% = $93.18. 
 
On May 14, 2022, the provider billed in the amount of $1,480 and the allowed amount is $384.36. $384.36 x 
20% = $76.87. The provider also billed in the amount of $1,794 and the allowed amount is $465.90. $465.90 x 
20% = $93.18. 
 
On May 17, 2022, the provider billed amount $7 and the allowed $1.82. This is less than the copayment 
amount. The provider also billed in the amount of $60 and the allowed amount is $15.58, and the plan paid 
$2.40. $15.58 - $2.40 = $13.18. This is less than the copayment amount. The provider billed in the amount of 
$1,794 and the allowed amount is $465.90. $465.90 x 20% = $93.18. 
 
On May 19, 2022, the provider billed in the amount of $1,480 and the allowed amount is $384.36. $384.36 x 
20% = $76.87.  The provider also billed in the amount of $1,794 and the allowed amount is $465.90. $465.90 x 
20% = $93.18. 
 
On May 21, 2022, the provider billed in the amount of $1,794 and the allowed amount is $465.90. $465.90 x 
20% = $93.18. 
 
On May 24, 2022, the provider billed amount $7 and the allowed $1.82. This is less than the copayment 
amount. The provider also billed in the amount of $60 and the allowed amount is $15.58, and the plan paid 
$2.40. $15.58 - $2.40 = $13.18. This is less than the copayment amount. The provider billed in the amount of 
$1,794 and the allowed amount is $465.90. $465.90 x 20% = $93.18.  
 
On May 31, 2022, the provider billed amount $7 and the allowed $1.82. This is less than the copayment 
amount. The provider also billed in the amount of $60 and the allowed amount is $15.58, and the plan paid 
$2.40. $15.58 - $2.40 = $13.18. This is less than the copayment amount. The provider billed in the amount of 
$1,794 and the allowed amount is $465.90. $465.90 x 20% = $93.18. $93.18 + $76.87 + $93.18 +$1.82 + 
$13.18 + $93.18 + $76.87 + $93.18 + $93.18 +$1.82 + $13.18 + $93.18 + $1.82 + $13.18 + $93.18 = $851. 
Therefore, results in the total cost sharing amount of $851. 
 
You have been asked to pay a $1,82 copayment and a $13.18 copayment, which is less than the copayment for 
lab test and 20% coinsurance for outpatient dialysis. This item/service falls within the Outpatient hospital 
services and Services to treat kidney disease 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 lab test and outpatient dialysis on May 12, 2022, to May 31, 2022.