Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visits, diagnostic radiology services, 
laboratory services, an outpatient observation, an outpatient surgery, and specialist visits provided from 
September 16, 2022, to May 24, 2023. 
 
You asked the Plan to waive the copayment for ER visits, diagnostic radiology services, laboratory services, an 
outpatient observation, an outpatient surgery, self-administered drugs and specialist visits. You say that the 
enrollee should not be responsible for the cost share applied. The Plan denied your request. The Plan says this 
cost sharing was charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $90 copayment for emergency care in 2022, a $110 copayment for emergency care in 2023, a $160 
copayment per day, per provider, for diagnostic radiology, a $10 copayment per day, per provider for 
laboratory services, a $110 copayment for each observation visit, a $290 copayment for each outpatient 
hospital facility visit and a $45 copayment for each specialist visit.  
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. 
 
The enrollee has been asked to pay a $890.75 copayment for ER visits, diagnostic radiology services, 
laboratory services, an outpatient observation, an outpatient surgery, self-administered drugs and specialist 
visits.  
  Date of Service Service Rendered Copayment 
per Contract 
Copayment applied 
September 19, 2022 ER visit / 99284 $90 $90 
March 7, 2023 ER visit / 99284 $110 $110 
March 14, 2023 Specialist visit / 99213 $45 $45 
March 15, 2023 Hepatobiliary System Imaging / 78227 $160 $35 (which is less than 
the standard copayment) 
March 16, 2023 Laboratory services / 80025 $10 $10 
March 17, 2023 Ultrasound / 76705 $160 $35 (which is less than 
the standard copayment) 
March 19, 2023 Observation visit / G0379 $110 $110 
March 19, 2023 Self-administered drugs / A9270 Not covered  $75.75 
April 10, 2023 Specialist visit / 99214 $45 $45 
May 9, 2023 Specialist visit / 99214 $45 $45 
May 24, 2023 Outpatient surgery / 45380 $290 $290 
Total   $890.75 
 
 
The ER visits fall within the emergency care benefit category. The radiology and laboratory services fall within 
the diagnostic radiology tests benefit category. The observation stay falls within the outpatient hospital 
observation benefit category. The outpatient surgery falls within the outpatient surgery benefit category. The 
specialist visits fall within the physician/practitioner services benefit category. 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 waive the copayment for ER visits, diagnostic radiology services, laboratory services, an outpatient 
observation, an outpatient surgery, and specialist visits provided from September 16, 2022, to May 24, 2023.  
 
Benefits for the self-administered may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.