Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardioversion, elective, electrical 
conversion of arrhythmia; external (92960), inpatient hospital services, a computed tomography (CT) scan of 
bleed vessels in chest with contrast (71275), and an open biopsy or excision of lymph nodes in groin (38531) 
provided from July 7, 2021, to September 10, 2021. 
 
You asked the Plan to waive the copayment for a cardioversion, elective, electrical conversion of arrhythmia; 
external, inpatient hospital services, a computed tomography (CT) scan of bleed vessels in chest with contrast, 
and an open biopsy or excision of lymph nodes in groin. You say that despite 19 phone calls and a chat, you are 
not able to have $2,300 of medical expenses removed from your provider bills, and your problem with the Plan 
is the total lack of responsibility/care regarding the monitoring of the $3,400 out-of-pocket maximum 
copayment. You also say you were never able to figure out when you were approaching the limit or if/when 
you had fulfilled it. You also say that the only remedy you were offered was to pay the $2,300 that you should 
not owe and request a refund from your care provider, and when you asked about that you were told it could 
not be done. 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 a $295 
copayment each day for days 1 to 5 for Medicare-covered hospital care, and you pay these amounts until you 
reach the out-of-pocket maximum. You contract with the Plan also says that you must pay a $115 copayment 
for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physicians office 
or at a free-standing facility (such as a radiology center or medical clinic), and you pay these amounts until you 
reach the out-of-pocket maximum. You contract with the Plan also says that the diagnostic radiology services 
require specialized equipment beyond standard x-ray equipment and must be performed by specially trained or 
certified personnel, and an example includes, but is not limited to, specialized scans, such as a commuted 
tomography (CT) scan. You contract with the Plan also says that enrollees must pay a $295 copayment for 
Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited 
to hospital or other facility charges and physician or surgical charges. You pay these amounts until you reach 
the out-of-pocket maximum. Your contract with the Plan also says the most you will have to pay out-of-pocket 
for in-network covered Part A and Part B services in 2021 is $3,400. The amounts you pay for your 
copayments and coinsurance for in-network covered services count toward this maximum out-of-pocket 
amount. 
 
You have been asked to pay a $295 copayment for a cardioversion, elective, electrical conversion of 
arrhythmia; external. You also have been asked to pay a $295 copayment for an open biopsy or excision of 
lymph nodes in the groin. A cardioversion, elective, electrical conversion of arrhythmia; external and an open 
biopsy or excision of lymph nodes in groin fall within the outpatient surgery and other medical services 
provided at hospital outpatient facilities and ambulatory surgical centers benefit category. You have also been 
asked to pay a $295 copayment per day for days 1 to 5 for inpatient hospital services, which is a total of  
$1,475 ($295 x 5 = $1,475). Inpatient hospital services fall under the inpatient hospital care benefit category. 
You have also been asked to pay a $115 copayment for a computed tomography (CT) scan of bleed vessels in 
chest with contrast. A computed tomography (CT) scan of bleed vessels in chest with contrast falls under the 
outpatient diagnostic tests and therapeutic services and supplies benefit category.  
 
The Plan contract also clearly shows that that there is an in-network maximum out-of-pocket expense of 
$3,400. The record shows that the maximum out-of-pocket expenses had not been met at the time of services. 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 for a cardioversion, elective, electrical conversion of 
arrhythmia; external (92960), inpatient hospital services, a computed tomography (CT) scan of bleed vessels in 
chest with contrast (71275), and an open biopsy or excision of lymph nodes in groin (38531) provided from 
July 7, 2021, to September 10, 2021.  
 
Your complaint about the potentially poor customer service with the Plan is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.