Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the incision and drainage of hematoma, seroma or 
fluid collection (10140) provided May 10, 2022. We decided that the Plan does not have to waive the 
copayment for the hospital outpatient clinic visit (G0463) debridement, subcutaneous tissue (includes 
epidermis and dermis, if performed) first 20 sq cm or less (11042) selective debridement of the first 20 sq. cm 
of wound surface area (97597) application of multilayer compression system, leg (below knee), including ankle 
and foot (29581).  
 
You asked the Plan to waive the copayment for the outpatient wound care visits coded as 11042, 11040, 97597, 
11042, G0463 and 29581 provided May 3, 2022 to June 7, 2022.. You say that you are being charged two 
copays and for date of service May 10, 2022 you were charged a $300 copay. You took this Plan with the 
understanding you were responsible for a single copay for specific services. The Plan says that this cost sharing 
was charged correctly. 
 
We decided that the Plan has to waive the copayment for the incision and drainage of hematoma, seroma 
or fluid collection (10140) provided May 10, 2022.  
 
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 enrollees must pay $30 copay for certain wound care services. 
 
The Plan says you must pay $300 copay for procedure code 10140 provided May 10, 2022. Based on the Plan 
contract, however, you cannot be asked to pay more than $30 for the wound care services. The Plan states that 
the provider billed with a surgery revenue code, but the other wound care services were billed with the same 
revenue code. The Plan has not substantiated their reason for this service to not be classified as wound care. 
Therefore, we decided that the Plan has to waive the copayment for the incision and drainage of hematoma, 
seroma or fluid collection (10140) provided May 10, 2022.  
 
We also decided that the Plan does not have to waive the copayment for the hospital outpatient clinic 
visit (G0463) debridement, subcutaneous tissue (includes epidermis and dermis, if performed) first 20 sq 
cm or less (11042) selective debridement of the first 20 sq. cm of wound surface area (97597) application 
of multilayer compression system, leg (below knee), including ankle and foot (29581). 
 
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 $30 
copay for certain wound care services for the hospital outpatient clinic visits. Page 227 of the Evidence of 
Coverage also says that some clinics where you see providers may be owned by a hospital. When you receive 
services at these clinics you may have higher out-of-pocket costs because hospital-owned clinics may bill you 
for both the provider you see, and for the use of the facility the provider is in Therefore, we decided that the 
Plan does not have to waive the copayment for the hospital outpatient clinic visit (G0463) debridement, 
subcutaneous tissue (includes epidermis and dermis, if performed) first 20 sq cm or less (11042) selective 
debridement of the first 20 sq. cm of wound surface area (97597) application of multilayer compression 
system, leg (below knee), including ankle and foot (29581). 
 
 
 
 
 
 
 
 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.