Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient services provided from January 
15, 2021, to April 13, 2022. 
 
You asked the Plan to waive the cost share for outpatient services. You say that these services should be 
covered. The Plan denied your request. The Plan says the cost share applied is correct. 
 
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 $1000 deductible which applies to outpatient surgery, imaging, and 
inpatient care. Your contract with the Plan says that you must pay a $350 copayment for each Medicare-
covered one-way trip via ground ambulance, a $30 copayment for Medicare- covered cardiac rehabilitation 
services, a $90 copayment for emergency care, a $35 copayment for diagnostic procedures and tests, a $40 
copayment for each Medicare-covered physical and speech therapy service, a $35 copayment for physician 
specialist services and a $400 copayment for each Medicare-covered outpatient surgery. 
 
Date of Service Service Provided Allowed Amount Cost Share 
Amount 
Member 
Responsibility 
January 15, 2021 X-Ray $8.94 $1,000 deductible $8.94 
September 30, 2021 Knee Surgery $1,196.23 $1,000 deductible $14.97 
October 2, 2021- 
October 5, 2021 
Inpatient Hospital 
Stay 
$15,815.17 
($14,839.08) 
$1,000 deductible 
$390 copayment 
per day, for days 1 
to 5 
$976.09 
$743.50 
October 7, 2021 Specialist Visit $174.60 $35 copayment $35 
October 11,2021 Specialist Visit $116.19 $35 copayment $35 
October 11, 2021 Ambulance 
Transport 
$448.78 $350 copayment $350 
October 11, 2021 ER Visit $10,327.53 $90 copayment $90 
October 14, 2021- 
October 2,2021 
Physical Therapy 
Visits 
$2,870.43 $40 copayment $200 
October 18, 2021 Specialist Visit $122.87 $35 copayment $35 
October 26, 2021 Specialist Visit $192.18 $35 copayment $35 
November 3, 2021 Imaging $13.82 $35 copayment $13.82 
November 10, 2021 Specialist Visit $86.40 $35 copayment $35 
November 2, 2021- 
November 18, 2021 
Physical Therapy 
Visits 
$2,923.30 $40 copayment/ 
visit 
$240 
November 19, 
2021- November 
29, 2021 
Cardiac 
Rehabilitation 
$238.70 $30 copayment/ 
visit 
$60 
December 2, 2021- 
December 30,2021 
Cardiac 
Rehabilitation 
$954.80 $30 copayment/ 
visit 
$240 
December 23, 2021 Specialist Visit $104.44 $35 copayment $35 
April 13, 2022 Anesthesia $114.78 $1,000 deductible $114.78 
April 13, 2022 Surgery $885.22 $1,000 deductible $885.22 
April 13, 2022 Surgery $119.35 $400 $119.68 
Total:    $4,267 The services you asked the Plan to waive the cost share for fall within the Ambulance Services, Cardiac 
Rehabilitation Services, Emergency Care, Outpatient Diagnostic Tests and Therapeutic Services and Supplies, 
Outpatient Rehabilitation Services, Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers and Physician/Practitioner Services, Including Doctors Office 
Visits benefit categories. 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 cost share for outpatient services provided 
from January 15, 2021, to April 13, 2022.