Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection of diagnostic or therapeutic 
substance (anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, 
including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with 
imaging guidance (62323) provided on July 20, 2021. 
 
You asked the Plan to waive the copayment for an injection of diagnostic or therapeutic substance (anesthetic, 
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 
placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance.  You say that your problem with the billing is that the $350 copayment is just not right, when the Plan will 
accept and cover this charge for an injection as an outpatient surgery. You also say that the fact that you can go 
into a hospital and have a surgeon perform an operation under anesthesia that will require not only an 
"injection" but an actual surgical procedure that may take hours, not minutes, and is billed as an outpatient 
surgery if one is released the same day, and your copayment would be the same as your copayment for an 
injection. You also say that just seems wrong. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment per visit for outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You have been asked to pay a $350 copayment for an injection of diagnostic or therapeutic substance 
(anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including 
needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging 
guidance. An injection of diagnostic or therapeutic substance (anesthetic, antispasmodic, opioid, steroid, other 
solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or 
subarachnoid, lumbar or sacral (caudal); with imaging guidance falls within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayment for an injection of diagnostic or therapeutic substance (anesthetic, 
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 
placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (62323) 
provided on July 20, 2021.