Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost sharing for the soft tissue neck CT scan provided on 
February 7, 2022, and the office visit provided on February 11, 2022, and the Plan has to reduce the cost 
sharing for the nuclear medicine study provided on October 19, 2022. We decided that the Plan does not 
have to waive the cost sharing for the CT scans, the ultrasound, the nuclear medicine study, and the radiation 
therapy services provided from July 21, 2022, to October 19, 2022. 
 
You asked the Plan to waive the cost sharing for the office visit, the CT scans, the ultrasound, the nuclear 
medicine study, and the radiation therapy services. You say that you met your maximum out-of-pocket. The 
Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the cost sharing for the soft tissue neck CT scan provided on 
February 7, 2022, and the office visit provided on February 11, 2022. 
 
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 did not provide the Explanation of Benefits (EOBs) for 
the services received on dates of service February 7, 2022, and February 11, 2022. Therefore, we decided that 
the Plan has to waive the cost sharing for the soft tissue neck CT scan provided on February 7, 2022, and the 
office visit provided on February 11, 2022. 
 
We decided that the Plan has to reduce the cost sharing for the nuclear medicine study provided on 
October 19, 2022. 
 
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 says that enrollees must pay a $150 
copayment for nuclear medicine services provided at a freestanding radiological facility. The Plan says you 
must pay $375.02 for the nuclear medicine study. Based on the Plan contract, however, you cannot be asked to 
pay more than $150 for the nuclear medicine study. Therefore, we decided that the Plan has to reduce the cost 
sharing for the nuclear medicine study. 
 
We also decided that the Plan does not have to waive the cost sharing for the CT scans, the ultrasound, 
the nuclear medicine study, and the radiation therapy services provided from July 21, 2022, to October 
19, 2022.   
 
 
 
 
 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 $15 
copayment for advanced imaging services provided in a specialists office, a $25 copayment for basic 
radiological services performed at a freestanding radiological facility, a 20% coinsurance for radiation therapy 
services provided in all places of service, and a $150 copayment for nuclear medicine services provided at a 
freestanding radiological facility. 
 
The record shows your maximum out-of-pocket was not met prior to receiving these services. You have been 
asked to pay a $15 copayment for each CT scan ($15 copayment x 7 services = $105). You have been asked to 
pay a $25 copayment for the ultrasound. You have also been asked to pay up to a 20% coinsurance for the 
radiation therapy services. These items/services fall within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. 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 sharing for the CT 
scans, the ultrasound, the nuclear medicine study, and the radiation therapy services provided from July 21, 
2022, to October 19, 2022. 
 
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.