Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and coinsurance for specialist office visits and 
trigger point injections with ultrasonic guidance provided on January 19, 2021, May 24, 2021, August 12, 
2021, and September 20, 2021. We also decided that the Plan does not have to waive the copayments and 
coinsurance for a specialist office visit, X-rays of the foot, and a trigger point injection provided on January 26, 
2021. 
 
You asked the Plan to waive the copayments and coinsurance for the specialist office visits, X-rays, and 
injections with ultrasonic guidance. You say that you were charged 4 copayments for one visit. The Plan denied 
your request. The Plan says the correct copayments and coinsurance were applied. 
 
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 $50 
copayment for each specialist visit. 
 
Your contract with the Plan clearly says that you must pay a 20% coinsurance for each Part B drug, including 
injectable drugs. 
 
Your contract with the Plan clearly says that you must pay a$150 copayment for diagnostic radiology services, 
not including X-rays. 
 
Your contract with the Plan clearly says that you must pay a $15 copayment for each standard X-ray service. 
 
Procedure/Drug Allowed Amount Copayment/20% Coinsurance 
Office Visit - January 19, 2021 - $50 (copayment) 
Injection - January 19, 2021 $2.66 $0.53 (coinsurance) 
Office Visit - January 26, 2021 - $50 (copayment) 
Foot X-rays - January 26, 2021 - $15 (copayment) 
Injection - January 26, 2021 $2.66 $0.53 (coinsurance) 
Injection - January 26, 2021 $0.26 $0.05 (coinsurance) 
Office Visit - May 24, 2021 - $50 (copayment) 
Ultrasonic Guidance - May 24, 2021 - $103.09 (copayment) 
Office Visit - August 12, 2021 - $50 (copayment) 
Ultrasonic Guidance - August 12, 2021 - $103.09 (copayment) 
Office Visit - September 20, 2021 - $50 (copayment) 
Ultrasonic Guidance - September 20, 2021 - $103.09 (copayment) 
Total:  $575.38 
 
You have been asked to pay $575.38 for the specialist office visits, X-rays, and injections with ultrasonic 
guidance. The specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office 
Visits benefit category. The X-rays and ultrasonic guidance fall within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. The injections fall within the Medicare Part B Prescription 
Drugs 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 copayments and coinsurance for specialist 
office visits and trigger point injections with ultrasonic guidance provided on January 19, 2021, May 24, 2021, 
August 12, 2021, and September 20, 2021. We also decided that the Plan does not have to waive the copayments and coinsurance for a specialist office visit, X-rays of the foot, and a trigger point injection provided on January 26, 2021.