Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayments for physical therapy services provided from April 10, 
2018, to May 31, 2018. We also decided that the Plan does not have to waive the copayments for physical 
therapy services provided from July 1, 2019, to July 26, 2019.  
 
 
You asked the Plan to waive the copayments for physical therapy services. You say that you never received a 
bill until July 2021 for services in 2018 and 2019. You also say that you closed out all financial responsibility 
with the facility over a year ago.  The Plan says that you have been charged the correct cost sharing amount. 
 
We decided that the Plan has to waive the copayments for physical therapy services provided from April 
10, 2018, to May 31, 2018.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided an explanation of benefits or other documentation 
showing patient liability for dates of service from April 10, 2018, to May 31, 2018. Therefore, without this 
information we are unable to determine if the applied cost sharing is correct. We decided that the Plan has to 
waive the copayments for physical therapy services provided from April 10, 2018, to May 31, 2018.  
 
We also decided that the Plan does not have to waive the copayments for physical therapy services 
provided from July 1, 2019, to July 26, 2019. 
 
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 for 
each physical therapy visit. 
 
You have been asked to pay a total of $180, which is a $20 copayment for each physical therapy service from 
July 1, 2019, to July 10, 2019, and from July 17, 2019, to July 26, 2019 ($20 copayment x 9 visits = $180). 
You have also been asked to pay the amount of $13.67, which is less than the $20 copayment for the physical 
therapy service on July 15, 2019. You have been asked to pay a total of $193.67 ($180 + $13.67 = $193.67). 
Physical therapy services fall within the Outpatient Rehabilitation Services 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 copayments for physical therapy services provided from July 1, 2019, to July 26, 
2019.  
 
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.