Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to make an additional payment for the application of a long arm cast (29065) rendered on August 18, 2021. We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99214), the coinsurance for the casting materials/supplies (Q4006), and an injection of Methylprednisolone (J1030, 20551) also rendered on August 18, 2021.
You asked the Plan to make an additional payment for the application of a cast. You also asked the Plan to waive the copayment for an office visit with a specialist, the coinsurance for the casting materials/supplies, and an injection of Methylprednisolone. You say that you only had a fracture repaired and that you paid the copayments for the office as you went. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.
We decided that the Plan has to make an additional payment for the application of a long arm cast.
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 did not provide a rule to support that the service of the application of a long arm cast was coded incorrectly. We find no obvious error in how this service was coded. As you are being billed by the provider for this denied charge, and the Plan has not provided a denial rationale, we find that the non-payment for this service is not substantiated.
Therefore, we decided that the Plan has to make an additional payment for the application of a long arm cast
(29065).
We also decided that the Plan does not have to waive copayment for an office visit with a specialist, the coinsurance for the casting materials/supplies, nor the coinsurance for an injection of Methylprednisolone.
Therefore, we decided that the Plan does not have to waive copayment for an office visit with a specialist, the coinsurance for the casting materials/supplies, nor the coinsurance for an injection of Methylprednisolone.
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 $50 copayment for a specialist's office, a 20% coinsurance for Medicare Part B Prescription Drugs, and a 20% coinsurance for medical supplies provided for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a $50 copayment for an office visit with a specialist. You have also been asked to pay $6.12 in coinsurance, which is 20% of the allowed amount for the casting materials/supplies ($30.60 allowed amount x 20% coinsurance = $6.12). The application of a long arm cast falls under the outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to pay $2.22 in coinsurance, which is 20% of the allowed amount for an injection of Methylprednisolone ($11.10 allowed amount x 20% coinsurance = $2.22). An injection of Methylprednisolone falls within the Medicare Part B prescription drugs 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 copayment for an office visit with a specialist (99214). We have also decided that the Plan does not have to waive the coinsurance for the casting materials/supplies (Q4006), and an injection of Methylprednisolone (J1030, 20551) rendered on August 1, 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.
Please note that if the provider is asking you to pay more than your cost sharing amount for the services rendered on the August 18, 2021 date of service, then contact the Plan. Please also note that if the provider is continuing to bill you for the copayment that you already paid, then you may wish to contact the provider to question this.
Your complaint about potentially fraudulent activity from the physician's office is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.