Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to waive the copayments for the cardiac rehabilitation services provided from August 1, 2021, to August 16, 2021. We decided that the Plan does not have to waive the copayments for the cardiac rehabilitation services provided from June 2, 2021, to July 31, 2021.

You asked the Plan to waive the copayments for the cardiac rehabilitation services. You say that you feel that the services would have ended sooner if there had been timely billing. The Plan says that you have been charged the correct cost sharing amount.

We decided that the Plan has to waive the copayments for the cardiac rehabilitation services provided from August 1, 2021, to August 16, 2021.

The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE).

Specifically, the Plan has not forwarded a copy of your August 2021 Explanation of Benefits (EOB). Without this information, we are unable to verify the cost share amounts applied to any services rendered in August 2021. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial is not substantiated, so we must find in your favor. Therefore, we decided that the Plan has to waive the copayments for the cardiac rehabilitation services provided from August 1, 2021, to August 16, 2021.

We also decided that the Plan does not have to waive the copayments for the cardiac rehabilitation services provided from June 2, 2021, to July 31, 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 clearly says that you must pay a $30 copayment for each cardiac rehabilitation visit at an outpatient hospital.

The file shows that you had a total of 13 visits for cardiac rehabilitation from June 2, 2021, to July 31, 2021. You have been asked to pay a $30 copayment for each visit, for a total of $390 ($30 copayment x 13 visits = $390). The cardiac rehabilitation services fall within the Cardiac Rehabilitation Services benefit category.

The file also shows that you had a total of 5 visits for laboratory services from June 2, 2021, to July 31, 2021. You have been asked to pay a $10 copayment for each visit, for a total of $50 ($10 copayment x 5 visits = $50). The laboratory services 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 copayments for the cardiac rehabilitation services provided from June 2, 2021, to July 31, 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.