Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the X-rays. We also decided that the Plan does not
have to waive the deductible or coinsurance for the injection. We also decided that the Plan does not have to
waive the copayment or coinsurance for the MRI and contrast agent.
You asked the Plan to waive the deductible, copayments, and coinsurance for the injection, MRI with contrast,
and X-rays. You say that you are on a limited income and cannot afford the charges. The Plan says that the
correct amount was applied to your deductible. The Plan also says the correct coinsurance and copayment
amounts have been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible which applies to certain items and services.
Your contract with the Plan also clearly says that you must pay a $300 copayment for diagnostic radiology
services at a free-standing radiology clinic, including MRI's.
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for medical supplies,
including contrast agents.
Your contract with the Plan also clearly says that you must pay a $5 copayment for X-rays at a free-standing
radiology clinic.
We decided that the Plan has to reduce the copayment for the X-rays.
You have been asked to pay a $50 copayment for the X-rays. Based on the Plan contract, however, you cannot
be asked to pay more than $5 for X-rays provided at a free-standing radiological facility. We looked at the file,
and we found no evidence that the X-rays were provided at an outpatient hospital. Therefore, we decided that
the Plan has to reduce the copayment for the X-rays from $50 to $5.
We also decided that the Plan does not have to waive the deductible or coinsurance for the injection. We
also decided that the Plan does not have to waive the copayment or coinsurance for the MRI and
contrast agent.
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Surgery,
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not
been fully met at the time the injection was received on July 7, 2021. The file shows that your deductible was met during this procedure. Therefore, you have also been asked to pay
$100.27 which is 50% of the allowed amount remaining for the injection, after the deductible was met ($200.54
allowed amount remaining x 50% coinsurance = $100.27). This mean 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.
You have also been asked to pay a $300 copayment for the MRI. The MRI falls 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.
You have also been asked to pay $5.83, which is 20% of the allowed amount for the contrast agent ($29.16
allowed amount x 20% coinsurance = $5.83). The contrast agent falls 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.
We looked at the file. We decided that the Plan does not have to waive the deductible or coinsurance for the
sacroiliac injection provided on July 7, 2021. We also decided that the Plan does not have to waive the
copayment for magnetic resonance imaging (MRI) provided on July 8, 2021. We also decided that the Plan
does not have to waive the coinsurance for a gadoterate meglumi (contrast agent) injection provided on July 8,
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.