Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ultrasound study of arteries and arterial 
grafts of both legs (93925), an ultrasound study of arteries of both arms and legs, complete (93923), an 
ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function 
(93306), and an ultrasound scan of veins of both arms or legs including assessment of compression and 
functional maneuvers (93970) provided on September 7, 2021.We also decided that the Plan does not have to 
waive the copayment for an ultrasound scan of veins of both arms or legs including assessment of compression 
and functional maneuvers (93970), an office visit (99202) and a routine electrocardiogram (EKG) using at least 
12 leads including interpretation and report (93000) also provided on September 7, 2021. 
 
You asked the Plan to waive the deductible for an ultrasound study of arteries and arterial grafts of both legs, 
an ultrasound study of arteries of both arms and legs, complete, an ultrasound examination of heart including 
color-depicted blood flow rate, direction, and valve function, and an ultrasound scan of veins of both arms or 
legs including assessment of compression and functional maneuvers. You also asked the Plan to waive the 
copayment for an ultrasound scan of veins of both arms or legs including assessment of compression and 
functional maneuvers an office visit and a routine electrocardiogram (EKG) using at least 12 leads including 
interpretation and report. You say that you were never told the tests would cost you a fortune. The Plan denied 
your request. The Plan says you were charged the correct cost sharing amount. 
 
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 $500 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. Your contract with the Plan also says that enrollees must pay a $20 
copayment for Medicare-covered non-radiological diagnostic services, including electrocardiograms (EKG). 
Your contract with the Plan also says that enrollees must pay a $35 copayment for services obtained from a 
specialist, or under certain circumstances, treatment by a nurse practitioner or physicians assistant or other 
non-physician health care professionals in a specialists office. Your contract with the Plan also says that there 
is a $160 copayment for Medicare-covered radiological diagnostic services, not including x-rays performed in a 
physicians office or at a free-standing facility. 
 
You have been asked to pay $224 for an ultrasound study of arteries and arterial grafts of both legs, $91.95 for 
an ultrasound study of arteries of both arms and legs, complete, $148.20 for an ultrasound examination of heart 
including color-depicted blood flow rate, direction, and valve function, and $35.70 for an ultrasound scan of 
veins of both arms or legs including assessment of compression and functional maneuvers. An ultrasound study 
of arteries and arterial grafts of both legs, an ultrasound study of arteries of both arms and legs, complete, an 
ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function, and an 
ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers 
fall within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to 
outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation 
that had not been met at the time an ultrasound study of arteries and arterial grafts of both legs, an ultrasound 
study of arteries of both arms and legs, complete, an ultrasound examination of heart including color-depicted 
blood flow rate, direction, and valve function, and an ultrasound scan of veins of both arms or legs including 
assessment of compression and functional maneuvers was received on September 7, 2021.  
 
You were also asked to pay $136.86, which is less than the $160 copayment, since the deductible was met 
during the ultrasound scan of veins of both arms or legs including assessment of compression and functional 
maneuvers. You were also asked to pay a $35 copayment for an office visit. You were also asked to pay $11.33, which is less than the $20 copayment for a routine electrocardiogram (EKG) using at least 12 leads 
including interpretation and report.  
 
Therefore, we decided that the Plan does not have to waive the deductible for an ultrasound study of arteries 
and arterial grafts of both legs (93925), an ultrasound study of arteries of both arms and legs, complete (93923), 
an ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function 
(93306), and an ultrasound scan of veins of both arms or legs including assessment of compression and 
functional maneuvers (93970) provided on September 7, 2021. We also decided that the Plan does not have to 
waive the copayment for an ultrasound scan of veins of both arms or legs including assessment of compression 
and functional maneuvers (93970), an office visit (99202) and a routine electrocardiogram (EKG) using at least 
12 leads including interpretation and report (93000) also provided on September 7, 2021