Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography (93306),  Duplex scan of extracranial arteries; complete bilateral study (93880),  transcranial Doppler study of the intracranial arteries; complete study (93886), duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study (93925), duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study (93931), and duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study (93970) provided December 15, 2020.  You asked the Plan to waive the copayments for the ultrasound of heart, ultrasound of both sides of head and neck blood flow, complete ultrasound of within the brain blood flow, ultrasound of leg arteries or artery grafts, ultrasound of one arm arteries or artery grafts and ultrasound study of arm or leg veins with compression and maneuvers. You say that you did not expect the ultrasounds to be broken up with individual copayments. You would like to be charged for 1 ultrasound copayment. The Plan denied your request. The Plan says the copayments were applied correctly.  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 $155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility  You have been asked to pay a total of $896.58 in copayments for the ultrasound of heart, ultrasound of both sides of head and neck blood flow, complete ultrasound of within the brain blood flow, ultrasound of leg arteries or artery grafts, ultrasound of one arm arteries or artery grafts and ultrasound study of arm or leg veins with compression and maneuvers. These 6 ultrasounds fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay less than or equal to the correct amount for each ultrasound 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 the echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography (93306),  Duplex scan of extracranial arteries; complete bilateral study (93880),  transcranial Doppler study of the intracranial arteries; complete study (93886), duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study (93925), duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study (93931), and duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study (93970) provided December 15, 2020.