Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for lab services provided on March 31, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement and
the services provided. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the
contract is clear that for people at high risk of colorectal cancer, screening colonoscopy (or screening barium
enema as an alternative) is covered every 24 months. If you receive a separate additional non-preventive
evaluation and/or service, a copayment will apply. The Plan provided this chronology of care to explain the
cost share.
The records show that on May 22, 2017, you received the following service, 45380 (colonoscopy, flexible with
biopsy) and 45385 (colonoscopy, flexible with removal of tumors), for a diagnosis of Z86010 (personal history
of colonic polyps), D125 (benign neoplasm of sigmoid colon), D123 (benign neoplasm of transverse colon) and
D120 (benign of neoplasm of cecum).
On November 27, 2017, you received the following service, 45385 (colonoscopy, flexible with removal of
tumors), for a diagnosis of Z86010 (personal history of colonic polyps), D125 (benign neoplasm of sigmoid
colon), D123 (benign neoplasm of transverse colon) and D120 (benign of neoplasm of cecum).
On May 30, 2018, you received the following service, 45385 (colonoscopy, flexible with removal of tumors),
for a diagnosis of Z86010 (personal history of colonic polyps) D125 (benign neoplasm of sigmoid colon),
D123 (benign neoplasm of transverse colon) and K5730 (diverticulosis of large intestine without perforation).
On June 5, 2019, you received the following service, 45385 (colonoscopy, flexible with removal of tumors), for
a diagnosis of Z86010 (personal history of colonic polyps), D122 (benign neoplasm of ascending colon), D125
(benign neoplasm of sigmoid colon) and D123 (benign neoplasm of transverse colon).
On September 30, 2020, you received the following service, 45380 (colonoscopy, flexible with biopsy) and
45385 (colonoscopy, flexible with removal of tumors), for a diagnosis of Z86010 (personal history of colonic
polyps) and K635 (polyp of colon).
On March 31, 221 you received the following service, 45385 (colonoscopy, flexible with removal of tumors),
for a diagnosis of Z86010 (personal history of colonic polyps) and K635 (polyp of colon), K621 (rectal polyp)
and K5730 (diverticulosis of large intestine).
On March 31, 2021, you received the following services, 45385 (colonoscopy, flexible with removal of
tumors), for a diagnosis of Z86010 (personal history of colonic polyps) and K635 (polyp of colon), K621
(rectal polyp) and K5730 (diverticulosis of large intestine).
On April 5, 2021, the Plan received a claim for the colorectal cancer screening services provided by on March
31, 2021. On April 6, 2021, the plan processed this claim and assessed cost share for $281.60 as patient
responsibility because coverage for this benefit as a screening had previously been exhausted per the contract
benefit rules of coverage every 24 months.
On April 6, 2021, the plan received and processed a claim for the colorectal cancer screening services provided
by on March 31, 2021. The claim assessed a $535.28 patient responsibility because the Plan already paid this
benefit based on the coverage rules of every 24 months. On June 5, 2019, you received the following service, 45385 (colonoscopy, flexible with removal of tumors), for
a diagnosis of Z86010 (personal history of colonic polyps), D122 (benign neoplasm of ascending colon), D125
(benign neoplasm of sigmoid colon) and D123 (benign neoplasm of transverse colon).
On September 30, 2020, you received the following service, 45380 (colonoscopy, flexible with biopsy) and
45385 (colonoscopy, flexible with removal of tumors), for a diagnosis of Z86010 (personal history of colonic
polyps) and K635 (polyp of colon).
On March 31, 221 you received the following service, 45385 (colonoscopy, flexible with removal of tumors),
for a diagnosis of Z86010 (personal history of colonic polyps) and K635 (polyp of colon), K621 (rectal polyp)
and K5730 (diverticulosis of large intestine).
On March 31, 2021, you received the following services, 45385 (colonoscopy, flexible with removal of
tumors), for a diagnosis of Z86010 (personal history of colonic polyps) and K635 (polyp of colon), K621
(rectal polyp) and K5730 (diverticulosis of large intestine).
On April 5, 2021, the Plan received a claim for the colorectal cancer screening services provided by on March
31, 2021. On April 6, 2021, the plan processed this claim and assessed cost share for $281.60 as patient
responsibility because coverage for this benefit as a screening had previously been exhausted per the contract
benefit rules of coverage every 24 months.
On April 6, 2021, the plan received and processed a claim for the colorectal cancer screening services provided
by on March 31, 2021. The claim assessed a $535.28 patient responsibility because the Plan already paid this
benefit based on the coverage rules of every 24 months.The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan states a screening colonoscopy for high-risk enrollees is
covered every 24 months and any extra services, such as a biopsy or polyp removal would incur additional cost
share.
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 cost share for colorectal and biopsy services provided on March 31, 2021.