Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayments for radiation therapy provided on November 16, 2021, 
November 17, 2021, and November 19, 2021. We decided that the Plan does not have to waive the copayments 
for radiation therapy provided on November 5, 2021, November 8, 2021, November 18, 2021, November 22, 
2021, November 24, 2021, and November 29, 2021..  
 
You asked the Plan to waive the copayments for radiation therapy. You say that you did not have services 
rendered on these dates of service. The Plan says that you have been charged the correct cost sharing amount. 
 
We decided that the Plan has to waive the copayments for radiation therapy provided on November 16, 
2021, November 17, 2021, and November 19, 2021.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records for dates of service November 16, 
2021, November 17, and November 19, 2021. Without the medical records we are unable to confirm if services 
were rendered on those dates and cannot determine if the cost sharing applied is correct. Therefore, we decided 
that the Plan has to waive the copayments for radiation therapy provided on November 16, 2021, November 17, 
2021, and November 19, 2021.  
 
We also decided that the Plan does not have to waive the copayments for radiation therapy provided on 
November 5, 2021, November 8, 2021, November 18, 2021, November 22, 2021, November 24, 2021, and 
November 29, 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 $60 
copayment for radiation therapy. 
 
The medical record shows you received radiation therapy on November 5, 2021, November 8, 2021, November 
18, 2021, November 22, 2021, November 24, 2021, and November 29, 2021. You have been asked to pay a 
$60 copayment for each radiation therapy visit. Radiation therapy falls 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 radiation therapy provided on November 5, 2021, November 8, 2021, November 18, 2021, November 22, 
2021, November 24, 2021, and November 29, 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.