Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for physical therapy visits provided from 
January 3, 2022, to March 21, 2022.  
 
You asked the Plan to reduce the cost share for therapy visits. You say that you advised the enrollee that their 
benefits changed since last year. The Plan denied your request. The Plan says the enrollee has been 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $750 out-of-network deductible which applies to outpatient rehabilitation services. The contract 
also say that you must pay 20% coinsurance after the deductible is met for each out-of-network physical therapy visit. 
 
The enrollee had not met their out-of-network deductible prior to the processing of these claims. The enrollee 
has also been asked to pay 20% coinsurance after the deductible was met for the therapy visits from January 3, 
2022, to March 21, 2022. Therapy visits fall within the Outpatient Rehabilitation Services benefit category.  
 
Date Code Allowed Amount Deductible 20% Coinsurance 
January 3, 2022 97110 $26.71  $5.34 
January 3, 2022 97140 $24.89  $4.98 
January 3, 2022 97112 $30.52  $6.10 
January 3, 2022 97530 $44.12  $8.82 
Total    $25.24 
January 5, 2022 97110 $26.71  $5.34 
January 5, 2022 97140 $24.89  $4.98 
January 5, 2022 97112 $30.52  $6.10 
January 5, 2022 97530 $44.12  $8.82 
Total    $25.24 
January 12, 2022 97110 $26.71 $26.71  
January 12, 2022 97140 $24.89 $24.89  
January 12, 2022 97112 $30.52 $30.52  
January 12, 2022 97530 $44.12 $44.12  
Total   $126.24  
January 21, 2022 97110 $26.71 $26.71  
January 21, 2022 97140 $24.89 $24.89  
January 21, 2022 97112 $30.52 $30.52  
January 21, 2022 97530 $44.12 $44.12  
Total   $126.24  
January 24, 2022 97110 $26.71  $5.34 
January 24, 2022 97140 $24.89  $4.98 
January 24, 2022 97112 $30.52  $6.10 
January 24, 2022 97530 $44.12  $8.82 
Total    $25.24 
January 31, 2022 97110 $26.71  $5.34 
January 31, 2022 97140 $24.89  $4.98 
January 31, 2022 97112 $30.52  $6.10 
January 31, 2022 97530 $44.12  $8.82 
Total    $25.24 
February 2, 2022 97110 $26.71 $21.86 $0.97 
February 2, 2022 97140 $24.89  $4.98 
February 2, 2022 97112 $30.52  $6.10 
February 2, 2022 97530 $44.12  $8.82 
Total   $21.86 $20.87 
February 9, 2022 97110 $26.71  $5.34 
February 9, 2022 97140 $24.89  $4.98 
February 9, 2022 97112 $30.52  $6.10 
February 9, 2022 97530 $44.12  $8.82 
Total    $25.24 
February 14, 2022 97110 $49.78  $9.96 
February 14, 2022 97140 $34.68  $6.94 
Total    $16.90 
 Date Code Allowed Amount Deductible 20% Coinsurance 
February 21, 2022 97110 $26.71 $26.71  
February 21, 2022 97164 $81.49 $81.49  
February 21, 2022 97112 $30.52 $30.52  
Total   $138.72  
February 23, 2022 97110 $26.71 $26.71  
February 23, 2022 97140 $24.89 $24.89  
February 23, 2022 97112 $30.52 $30.52  
February 23, 2022 97530 $44.12 $44.12  
Total   $126.24  
March 2, 2022 97110 $26.71 $26.71  
March 2, 2022 97140 $24.89 $24.89  
March 2, 2022 97112 $30.52 $30.52  
March 2, 2022 97530 $44.12 $44.12  
Total   $126.24  
March 4, 2022 97110 $26.71  $5.34 
March 4, 2022 97164 $81.49  $16.30 
March 4, 2022 97112 $30.52  $6.10 
March 4, 2022 97530 $31.29  $6.26 
Total    $34.00 
March 7, 2022 97110 $53.42  $10.68 
March 7, 2022 97112 $30.52  $6.10 
March 7, 2022 97530 $44.12  $8.82 
Total    $25.60 
March 11, 2022 97110 $26.71  $5.34 
March 11, 2022 97140 $24.89  $4.98 
March 11, 2022 97112 $30.52  $6.10 
March 11, 2022 97530 $44.12  $8.82 
Total    $25.24 
March 14, 2022 97110 $26.71  $5.34 
March 14, 2022 97140 $24.89  $4.98 
March 14, 2022 97112 $30.52  $6.10 
March 14, 2022 97530 $44.12  $8.82 
Total    $25.24 
March 16, 2022 97110 $53.42  $10.68 
March 16, 2022 97140 $24.89  $4.98 
March 16, 2022 97112 $30.52  $6.10 
March 16, 2022 97530 $44.12  $8.82 
Total    $30.58 
March 21, 2022 97110 $53.42  $10.68 
March 21, 2022 97140 $24.89  $4.98 
March 21, 2022 97112 $40.29  $8.06 
Total    $23.72 
 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to reduce the cost share for physical therapy visits provided from January 3, 
2022, to March 21, 2022.