Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reimburse to the full 70% coinsurance for physical therapy treatment, direct 
repair of aneurysm, pseudoaneurysm, or excision, an office visit, electrical stimulation, chiropractic 
manipulation, and therapeutic exercises. We also decided that the Plan does not have to reimburse all of the 
requested coinsurance for physical therapy treatment, direct repair of aneurysm, pseudoaneurysm, or excision, 
an office visit, electrical stimulation, chiropractic manipulation, and therapeutic exercises.  
 
You asked the Plan to reimburse $812 of coinsurance that you paid for physical therapy treatment, direct repair 
of aneurysm, pseudoaneurysm, or excision, an office visit, electrical stimulation, chiropractic manipulation, 
and therapeutic exercises. You say that under your plan benefits, you can receive chiropractic services 18 times 
per year of which you pay 30% and get reimbursed 70% of the total cost. You also say that your total cost for 
the 16 visits was $1,160 x 30% = $348, which you paid. You also say that the Plan should have paid you $812, 
which did not happen, and you request that the Plan reimburse you $812 for the 16 chiropractic visits you 
received and paid cash for on each day of service. The Plan says that they have reprocessed the enrollee's 
reimbursement request to pay additional amount of $606.10, which was made to the enrollee on February 14, 
2022, and they are upholding the reimbursement of $606.10 to the enrollee. 
 
We decided that the Plan has to reimburse to the full 70% coinsurance for physical therapy treatment, 
direct repair of aneurysm, pseudoaneurysm, or excision, an office visit, electrical stimulation, 
chiropractic manipulation, and therapeutic exercises.  
 
Medicare rules say that 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 says that you must pay a 30% 
copayment for each chiropractic visit. The coinsurance that the Plan reimbursed you for was calculated 
incorrectly. The Plan reimbursed you a total of $691.30 ($85.20 + $606.10 = $691.30). The  coinsurance 
amount you should have been reimbursed is $783.48 ($1,119.26 total allowed amount x 30% = $335.78), 
($1,119.26 total allowed amount - $335.78 = $783.48). This leaves an amount of $92.18 that should still be 
reimbursed ($783.48  $691.30 = $92.18). 
 
We also decided that the Plan does not have to reimburse all of the requested coinsurance for physical 
therapy treatment, direct repair of aneurysm, pseudoaneurysm, or excision, an office visit, electrical 
stimulation, chiropractic manipulation, and therapeutic exercises. 
 
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 chiropractic visit. You asked for a reimbursement of $812. Your coinsurance for these 
claims is $335.78 ($1,119.26 allowed amount x 30% = $335.78) and the reimbursement amount should have 
been $783.48 ($1,119.26 - $335.78 = $783.48).  Therefore, we decided that the Plan does not have to reimburse 
all of the requested amount for coinsurance ($812) for physical therapy treatment, direct repair of aneurysm, 
pseudoaneurysm, or excision, an office visit, electrical stimulation, chiropractic manipulation, and therapeutic 
exercises. 
 
 
 
 
 
 
 
 
 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.