Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost sharing for the radiation therapy services. We decided that 
the Plan does not have to waive the cost sharing for the radiation therapy services.  
 You asked the Plan to waive the cost sharing for the radiation therapy services provided by an out-of-network 
provider from August 15, 2022, to October 5, 2022. You say that you would like these services to be billed as 
in-network. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the cost sharing for the radiation therapy services.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan does not say in clear and accurate terms how much you should expect to pay for out-of-
network radiation therapy, as it is not clear if you must pay 10% or 20%.  
 
 
The Plan says you must pay a cost share of $2308.95, which is more than a 20% coinsurance for the out-of-
network radiation therapy services. Because the Plan contract is not clear if you must pay a 10 or 20% 
coinsurance, you cannot be asked to pay more than a 10% coinsurance for out-of-network radiation therapy 
services. Therefore, we decided that the Plan has to reduce the cost sharing for the radiation therapy services.  
 
 
 
 
 
Date of Service Procedure Code Allowed 
Amounts 
(Plan Paid + 
Coinsurance) 
Coinsurance 
Amount the Plan 
Applied 
(greater than 
20%) 
Coinsurance 
Amount We Find 
(x 10%) 
August 15, 2022 77290 $366.15 $73.23 $36.62 
August 15, 2022 77332 $137.16 $27.43 $13.72 
August 23, 2022 77295 $1364.52 $272.90 $136.45 
August 23, 2022 77300 $548.64 $109.73 $54.86 
August 23, 2022 77334 $1464.60 $292.92 $146.46 
August 29, 2022 77412 $261.28 $52.26 $26.13 
August 30, 2022 77412 $261.28 $52.26 $26.13 
August 31, 2022 77412 $261.28 $52.26 $26.13 
September 1, 2022 77370 $134.97 $27.43 $13.50 
September 1, 2022 77401 $257.10 $52.26 $25.71 
September 2, 2022 77401 $257.10 $52.26 $25.71 
September 6, 2022 77401 $257.10 $52.26 $25.71 
September 7, 2022 77401 $257.10 $52.26 $25.71 
September 8, 2022 77370 $134.97 $27.43 $13.50 
September 8, 2022 77401 $257.10 $52.26 $25.71 
September 12, 2022 77401 $257.10 $52.26 $25.71 
September 13, 2022 77301 $539.86 $109.73 $53.99 
September 13, 2022 77470 $1441.17 $292.92 $144.12 
September 13, 2022 77401 $257.10 $52.26 $25.71 
September 14, 2022 77401 $257.10 $52.26 $25.71 
September 15, 2022 77370 $134.97 $27.43 $13.50 
September 15, 2022 77401 $257.10 $52.26 $25.71 
September 16, 2022 77401 $257.10 $52.26 $25.71 
September 19, 2022 77401 $257.10 $52.26 $25.71 
September 20, 2022 77401 $257.10 $52.26 $25.71 
September 21, 2022 77401 $257.10 $52.26 $25.71 
September 22, 2022 77401 $257.10 $52.26 $25.71 
September 23, 2022 77370 $134.97 $27.43 $13.50 
September 23, 2022 77401 $257.10 $52.26 $25.71 We also decided that the Plan does not have to waive the cost sharing for the radiation therapy services. 
 
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 10-
20% coinsurance for out-of-network radiation therapy services, including technician materials and supplies. 
 
You are being held responsible to pay a 10% coinsurance for the radiation therapy services. These 
items/services fall 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 the radiation therapy services provided by an out-of-
network provider from August 15, 2022, to October 5, 2022. 
 
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.