Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost share for a specialist office visit provided on September 8, 
2021, and December 15, 2021. We decided that the Plan does not have to reduce the cost share for the toenail 
debridement provided on September 8, 2021, and December 15, 2021. 
 
You asked the Plan to reduce the cost share for a specialist office visit and toenail debridement. You say that 
you had the same services in May 2021 and were only charged a $35 copayment. You also say that you do not 
think this is fair and don't think that you should have to pay for services you did not have. The Plan says that 
you have been charged the correct cost sharing amount. 
 
We decided that the Plan has to reduce the cost share for a specialist office visit (code 99213) provided on 
September 8, 2021, and December 15, 2021. 
 
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 the deductible does not apply to a specialist office visit. 
 
The medical record shows you had a specialist office visit on September 8, 2021, and December 15, 2021. The 
Plan says you must pay a $750 deductible for a specialist office visit. Based on the Plan contract, however, you 
cannot be asked to pay more than a $35 copayment for a specialist office visit. Therefore, we decided that the 
Plan has to reduce the cost share for a podiatry specialist office visit provided on September 8, 2021, and 
December 15, 2021.  
 
We also decided that the Plan does not have to reduce the cost share for the toenail debridement (code 
11721) provided on September 8, 2021, and December 15, 2021. 
 
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 says there is a $750 deductible which 
applies to additional services performed on the same day in a physicians office. 
 
The medical record shows you received toenail debridement services on September 8, 2021, and December 15, 
2021. The toenail debridement you asked the Plan to reduce the cost share for falls within the Podiatry Services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to additional services performed on the same day in a physicians office. This cost 
sharing is a contractual obligation that had not been met at the time the toenail debridement was received on 
September 8, 2021, and December 15, 2021. Therefore, we decided that the Plan does not have to reduce the 
cost share for the toenail debridement on September 8, 2021, and December 15, 2021. 
 
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.