Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for Duplex scan of extracranial arteries, 
Echocardiography, Absolute quantitation of myocardial blood flow (AQMBF), Injection, Positron emission 
tomography (PET), and Cardiovascular stress test on February 09, 2021, to March 12, 2021. 
 You asked the Plan to waive the cost-sharing for diagnostic test and non-radiological diagnostic services. You 
say that you received the tests on those dates and never saw a doctor. The Plan denied your request. The Plan 
says the cost-sharing amounts you are being charged are correct. 
 
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 20% 
coinsurance for each Medicare-covered medical supply, $30 copayment for Medicare-covered non-radiological 
diagnostic services, and $155 copayment for Medicare-covered radiological diagnostic services. 
 
For February 9, 2021, the provider billed service in the amount of $440.00 and the allowed amount was 
$145.24. The enrollee is responsible for a cost share amount of $145.24 for this service. As the allowed amount 
of $145.24 was less than the copayment amount of $155.00 the member was only assessed a copayment of 
$145.24.  
 
For February 17, 2021, the provider billed service in the amount of $550.00 and the allowed amount was 
$171.00. The enrollee is responsible for a copayment amount of $155.00 for this service. In this case, $171.00 
Medicare-Allowed - $16.00 Plan Paid - $0.00 Sequestration = $155.00. 
 
For March 12, 2021, the provider billed service in the amount of $485.00 and the allowed amount was $154.42. 
The enrollee is responsible for a copayment amount of $154.42 for this service. As the allowed amount of 
$154.42 was less than the copayment amount of $155.00 the member was only assessed a copayment of 
$154.42. In this case, $154.42 Medicare-Allowed - $0.00 Plan Paid - $0.00 Sequestration = $154.42. 
 
For March 12, 2021, the provider billed service in the amount of $320.00 and the allowed amount was $236.76. 
The enrollee is responsible for a cost share amount of $47.35 for this service. In this case, $236.76 Medicare-
Allowed - $189.41 Plan Paid - $0.00 Sequestration = $47.35. 
 
For March 12, 2021, the provider billed service in the amount of $2,800.00 and the allowed amount was 
$1,356.27. The enrollee is responsible for a copayment amount of $155.00 for this service In this case, 
$1,356.27 Medicare-Allowed - $1,204.27 Plan Paid - $0.00 Sequestration =$155.00.  
 
For March 12, 2021, the provider billed service in the amount of $300.00 and the allowed amount was $56.91. 
The enrollee is responsible for a copayment amount of $30.00 for this service. In this case, $56.91 Medicare-
Allowed - $26.91 Plan Paid - $0.00 Sequestration = $30.00. Therefore, your total cost-sharing amount is 
$687.01.  
 
You have been asked to pay a 20% coinsurance for each Medicare-covered medical supply, $30 copayment for 
Medicare-covered non-radiological diagnostic services, and $155 copayment for Medicare-covered 
radiological diagnostic services. Medical supplies, non-radiological diagnostic services, and radiological 
diagnostic services 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 cost-sharing for Duplex scan of extracranial arteries, 
Echocardiography, Absolute quantitation of myocardial blood flow (AQMBF), Injection, Positron emission 
tomography (PET), and Cardiovascular stress test on February 09, 2021, to March 12, 2021.