Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and the coinsurance for an office visit, an 
electrocardiogram, an absolute quantitation of myocardial blood flow (AQMBF), positron emission 
tomography (PET) scan, a cardiovascular stress test, a regadenoson injection, a diagnostic Rubidium rb-82, a myocardial imaging PET scan, a transthoracic echocardiography, and an external electrocardiographic 
recording up to 48 hours provided from March 3, 2022, to March 23, 2022. 
 
You asked the Plan to waive the copayment and the coinsurance for an office visit, an electrocardiogram, an 
absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET) scan, a 
cardiovascular stress test, a regadenoson injection, a diagnostic Rubidium rb-82, a myocardial imaging PET 
scan, a transthoracic echocardiography, and an external electrocardiographic recording up to 48 hours. You say 
that you are being asked to pay several hundred dollars in copayments for procedures that you were not aware 
that you would have to pay. 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 that there is a 20% 
coinsurance for all other Medicare-covered in-network Part B drugs than allergy antigens. Your contract with 
the Plan also clearly says that you must pay 20% coinsurance for each Medicare-covered medical supply. Your 
contract with the Plan also says that you must pay a $20 copayment for Medicare-covered non-radiological 
diagnostic services, including electrocardiograms, pulmonary function tests, home of lab-based sleep studies, 
and treadmill stress tests. Your contract with the Plan also says you must pay a $110 copayment for Medicare-
covered radiological diagnostic services, not including x-rays, performed in a physicians office or at a free-
standing facility. You contract with the Plan also says that you must pay a $35 copayment for services obtained 
from a specialist or under certain circumstances, treatment by a nurse practitioner or physician's assistant or 
other non-physician health care professionals in a primary care provider's office.  
 
You have been asked to pay the following cost sharing amounts: 
 
Claim Number: Service: Date of Service: Allowed Amount: Copayment: 
034233266 Office Visit March 3, 2022 $121.57 $35 
034233266 Electrocardiogram March 3, 2022 $13.63 $13.63 
035724112 AQMBF March 21, 2022 $168.45 $110 
035724112 Stress Test March 21, 2022 $66.84 $20 
037989404 Echocardiography March 23, 2022 $186.83 $110 
037989404 Electrocardiographic Recording March 23, 2022 $56.98 $20 
  Total: $370.49 $308.63 
 
 
Claim Number: Service: Date of Service: Allowed Amount: Coinsurance: 
035724112 Regadenoson Inj. March 21, 2022 $238.80 $47.76 
035724112 Rubidium Rb-82 March 21, 2022 $1,041.50 $208.30 
  Total: $1,280.3 $256.06 
 
An office visit falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit 
category. An electrocardiogram, an absolute quantitation of myocardial blood flow (AQMBF), positron 
emission tomography (PET) scan, a cardiovascular stress test, a myocardial imaging PET scan, and a 
transthoracic echocardiography, and an external electrocardiographic recording up to 48 hours fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. A regadenoson injection 
and a diagnostic Rubidium rb-82 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 copayment and the coinsurance for an office visit, an electrocardiogram, an 
absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET) scan, a 
cardiovascular stress test, a regadenoson injection, a diagnostic Rubidium rb-82, a myocardial imaging PET scan, a transthoracic echocardiography, and an external electrocardiographic recording up to 48 hours provided 
from March 3, 2022, to March 23, 2022.