Appeal type: Outpatient Mental Health
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for mental health visits provided on August 17, 2021, 
August 19, 2021, August 24, 2021, and September 7, 2021. We decided that the Plan does not have to waive 
the copayment for all other mental health visits provided from August 17, 2021, to October 20, 2021. 
 You asked the Plan to waive the copayment for mental health visits provided from August 17, 2021, to October 
20, 2021. You say that you were told these treatments would be fully covered by the plan prior to committing 
to them. You say you proceeded with the transcranial magnetic stimulation (TMS) only after you were told the 
treatments were covered. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the copayment for mental health visits provided on August 17, 
2021, August 19, 2021, August 24, 2021, and September 7, 2021.  
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). The Plan did not submit an Explanation of Benefits or 
claim information providing the amount billed for the following service dates. 
 
Date of Service Service Type Service Code 
August 17, 2021 Group Psychotherapy 90853 
August 19, 2021 Transcranial Magnetic Stimulation (TMS) 90867 
August 24, 2021 Group Psychotherapy 90853 
September 7, 2021 Group Psychotherapy 90853 
 
Therefore, we decided that the Plan has to waive the copayment for mental health visits provided on August 17, 
2021, August 19, 2021, August 24, 2021, and September 7, 2021.  
 
We also decided that the Plan does not have to waive the copayment for all other mental health visits 
provided from August 17, 2021, to October 20, 2021. 
 
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 $40 
copayment for the following mental health visits provided from August 17, 2021, to October 20, 2021.   
 
 
 
  
Dates of Service Service Type and 
Code 
Number 
of Visits 
Allowed Copayment Applied Member 
Liability 
August 17, 2021 Office Visit (99214) 1 $110.44 $40 $40 
August 20, 2021, September 9, 
2021, September 17, 2021, 
and September 21, 2021 
Transcranial 
Magnetic Stimulation 
(TMS) (90868) 
4 $260.99 $40 per visit $160 
August 23, 2021 to October 
20, 2021 
TMS (90868) 27 $24.88 $24.88 per visit  
(Which is less than the 
standard $40 copayment) 
$671.76 
August 24, 2021 and 
September 7, 2021 
TMS (90868) 2 $24.88 $11.08 per visit 
(Which is less than the 
standard $40 copayment) 
$22.16 
August 31, 2021  TMS (90868) 1 $260.99 $11.08 per visit 
(Which is less than the 
standard $40 copayment) 
$11.08 
August 31, 2022 Group Psychotherapy 
(90853) 
1 $28.92 $28.92  
(Which is less than the 
standard $40 copayment) 
$28.92 
October 18, 2021 Individual Therapy 
(90834) 
1 $97.13 $40 $40 
Total     $973.92 Therefore, we decided that the Plan does not have to waive the copayment for all other mental health visits 
provided from August 17, 2021, to October 20, 2021. 
 
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.