Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis with contrast materials (74177) or waive the coinsurance for low osmolar contrast 
material, 300-399MG/ML iodine concentration (Q9967) provided on October 29, 2021. 
 
You asked the Plan to waive the copayment for a computed tomography (CT scan) of the abdomen and pelvis 
with contrast materials and to waive the coinsurance for low osmolar contrast material, 300-399MG/ML iodine concentration. You say that your doctor, nor any of his staff, ever ordered contrast for your computed 
tomography (CT) scan on your bad kidneys, and somehow, the rendering provider did this on their own. You 
also say that after your doctor found out, you had to monitor your kidney functions for 5 days. 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 $160 
copayment for Medicare covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic). You contract with 
the Plan also clearly says that the diagnostic radiology services require specialized equipment beyond standard 
x-ray equipment and must be performed by specially trained or certified personnel, and includes, but is not 
limited to, CT scans. You contract with the Plan also clearly says that enrollees must pay a 20% coinsurance 
for each Medicare-covered medial supply. You contract with the Plan also clearly says that supplies for which 
an appropriate separate charge is made by providers (such as, chemical agents used in certain diagnostic 
procedures) are subject to cost sharing as shown.   
 
You have been asked to pay a $160 copayment for a computed tomography (CT) scan of the abdomen and 
pelvis with contrast materials. You have also been asked to pay $2.60 in coinsurance, which is 20% of the 
allowed amount for a low osmolar contrast material, 300-399MG/ML iodine concentration ($13 allowed 
amount x 20% = $2.60). Computed tomography (CT) scans of the abdomen and pelvis with contrast materials  
and low osmolar contrast materials, 300-399MG/ML iodine concentration fall within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 a computed tomography (CT) scan of the abdomen and pelvis with contrast materials (74177) or waive the 
coinsurance for low osmolar contrast material, 300-399MG/ML iodine concentration (Q9967) provided on 
October 29, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.