Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic procedures to re-educate brain-
to nerve-to muscle function (97112), manual physical therapy techniques to one or more regions (97140), and therapeutic activities to improve function, with one-to-one contact between patient and provider (97530) 
provided from January 20, 2021, to September 20, 2021. 
 
You asked the Plan to waive the copayment for therapeutic procedures to re-educate brain-to nerve-to muscle 
function, manual physical therapy techniques to one or more regions, and therapeutic activities to improve 
function, with one-to-one contact between patient and provider. You say that you were told at your first 
physical therapy visit that there was no copayment because the Plan had waived the $40 because of the 
coronavirus (COVID-19), and you continued with many visits because you needed them and was encouraged 
to keep going by the therapists you saw. You also say that each time you went in for your appointment, you 
went to the front desk and was told you were checked in, and that no one ever said you needed to make a $40 
copayment. You also say that you assumed that the Plan had still waived the copayment, or you would not have 
continued to go for so many sessions, as you are a senior on a very limited social security income. The Plan 
denied your request. The Plan says you were charged the correct cost sharing amount. 
 
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 each Medicare-covered physical therapy and speech-language therapy visit, and a $40 
copayment for each Medicare-covered occupational therapy visit.  
 
You have been asked to pay a $40 copayment for each visit of therapeutic procedures to re-educate brain-to 
nerve-to muscle function, manual physical therapy techniques to one or more regions, and therapeutic activities 
to improve function, with one-to-one contact between patient and provider, for 13 visits, which is a total of 
$520 ($40 x 13 = $520). Therapeutic procedures to re-educate brain-to nerve-to muscle function, manual 
physical therapy techniques to one or more regions, and therapeutic activities to improve function, with one-to-
one contact between patient and provider 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 copayment for therapeutic procedures to re-educate brain-to nerve-to 
muscle function (97112), manual physical therapy techniques to one or more regions (97140), and therapeutic 
activities to improve function, with one-to-one contact between patient and provider (97530) provided from 
January 20, 2021, to September 20, 2021.  
 
Your complaint about potentially not being informed by the provider regarding the change in copayment status 
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.