Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for office visits, a tangential biopsy of the 
skin and other surgical services, tissue exams by pathologists and other pathology services, a complete 
electrocardiogram, a retroperitoneal ultrasound, Mohs surgery, a colonoscopy, and continued positive airway 
pressure (CPAP) device supplies provided from July 14, 2021, to December 2, 2021. 
 
You asked the Plan to waive the coinsurance for office visits, a tangential biopsy of the skin and other surgical 
services, tissue exams by pathologists and other pathology services, a complete electrocardiogram, a retroperitoneal ultrasound, Mohs surgery, a colonoscopy, and continued positive airway pressure (CPAP) 
device supplies. You say that the amount due is decreasing without you paying anything, and you have not paid 
anything to reduce the amount due. You also say someone recalculated and corrected it. 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 30% in 
coinsurance for each out-of-network service including the following: colorectal cancer screening; durable 
medical equipment (DME) and related supplies; outpatient diagnostic tests and therapeutic services and 
supplies; outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers; and physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay 30% in coinsurance for office visits, a tangential biopsy of the skin and other 
surgical services, tissue exams by pathologists and other pathology services, a complete electrocardiogram, a 
retroperitoneal ultrasound, Mohs surgery, a colonoscopy, and continued positive airway pressure (CPAP) 
device supplies. Office visits fall within the physician/practitioner services, including doctor's office visits 
benefit category. A tangential biopsy of the skin, Mohs surgery, and other surgical services fall under the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. Tissue exams by pathologists and other pathology services, a retroperitoneal ultrasound, and a 
complete electrocardiogram fall under outpatient diagnostic tests and therapeutic services and supplies benefit 
category. A colonoscopy falls under the colorectal cancer screening benefit category. Finally, continued 
positive airway pressure (CPAP) device supplies fall under the durable medical equipment (DME) and related 
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 coinsurance for office visits, a tangential 
biopsy of the skin and other surgical services, tissue exams by pathologists and other pathology services, a 
complete electrocardiogram, a retroperitoneal ultrasound, Mohs surgery, a colonoscopy, and continued positive 
airway pressure (CPAP) device supplies provided from July 14, 2021, to December 2, 2021.