Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost share for the wound care supplies provided on July 27, 2023, 
August 3, 2023, and august 28, 2023, and the ECG provided on August 28, 2023. We decided that the Plan 
does not have to waive the cost share for the podiatry services provided on July 24, 2023, July 27, 2023, 
August 3, 2023, August 10, 2023, August 21, 2023, August 24, 2023, August 28, 2023, September 7, 2023, 
September 11, 2023, September 25, 2023, and October 2, 2023, and the wound care supplies provided on 
August 21, 2023, September 7, 2023, and September 14, 2023.  
 
You asked the Plan to waive the cost share for the podiatry services, the wound care supplies and an ECG 
provided from July 24, 2023, to October 2, 2023. You say that you disagree with the cost share. The Plan says 
that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the cost share for the wound care supplies and the 
echocardiogram.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided an Explanation of Benefits (EOB) or other 
documentation showing how the cost share was applied. Therefore, we decided that the Plan has to waive the 
cost share for the wound care supplies provided on July 27, 2023, August 3, 2023, and august 28, 2023, and the 
ECG provided on August 28, 2023.  
 
We also decided that the Plan does not have to waive the cost share for the podiatry services, and the 
wound care supplies. 
 
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 a $35 
copayment for each Medicare-covered podiatry visit. Your contract with the Plan also clearly says that you 
must pay 20% coinsurance for durable medical equipment.  
 
You have been asked to pay a $35 copayment for each podiatry service provided on July 24, 2023, July 27, 
2023, August 3, 2023, August 10, 2023, August 21, 2023, August 24, 2023, August 28, 2023, September 7, 
2023, September 11, 2023, September 25, 2023, and October 2, 2023. These items/services fall within the 
podiatry services 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 20% coinsurance of the allowed amount for the wound care supplies provided 
on August 21, 2023, September 7, 2023, and September 14, 2023. These items/services fall within the durable 
medical equipment and related supplies 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. Therefore, we decided that the Plan does not have to waive the cost share for the 
podiatry services provided on July 24, 2023, July 27, 2023, August 3, 2023, August 10, 2023, August 21, 2023, 
August 24, 2023, August 28, 2023, September 7, 2023, September 11, 2023, September 25, 2023, and October 
2, 2023, and the wound care supplies provided on August 21, 2023, September 7, 2023, and September 14, 
2023. 
 
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.