Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy on January 23, 203, to 
February 01, 2023.   
 
You asked the Plan to waive the coinsurance for radiation therapy. You say that you want to appeal the amount 
being charged. 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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for radiation therapy. Covered services include but are not limited to radiation (radium and 
isotope) therapy including technician materials and supplies. 
 
 
 The provider billed for the following dates of service:  
 
January 23, 2023: Billed amount is $4,475 and the allowed amount is $1,977.39. The coinsurance is $395.48. 
January 26, 2023: Billed amount is $2,500 and the allowed amount is $1,272.66. The coinsurance is $254.53. 
January 26, 2023: Billed amount is $1,300 and the allowed amount is $493.59. The coinsurance is $98.72. 
January 26, 2023: Billed amount is $1,000 and the allowed amount is $625.52. The coinsurance is $125.10. 
January 26, 2023: Billed amount is $244 and the allowed amount is $67.19. The coinsurance is $13.44.  
January 26, 2023: Billed amount is $244 and the allowed amount is $67.19. The coinsurance is $13.44. 
January 26, 2023: Billed amount is $244 and the allowed amount is $67.19. The coinsurance is $13.44. 
January 26, 2023: Billed amount is $244 and the allowed amount is $67.19. The coinsurance is $13.44. 
January 26, 2023: Billed amount is $244 and the allowed amount is $67.19. The coinsurance is $13.44. 
January 26, 2023: Billed amount is $244 and the allowed amount is $67.19. The coinsurance is $13.44. 
January 26, 2023: Billed amount is $244 and the allowed amount is $67.19. The coinsurance is $13.44. 
January 26, 2023: Billed amount is $244 and the allowed amount is $67.19. The coinsurance is $13.44. 
January 26, 2023: Billed amount is $244 and the allowed amount is $67.19. The coinsurance is $13.44. 
January 26, 2023: Billed amount is $244 and the allowed amount is $67.19. The coinsurance is $13.44. 
January 27, 2023: Billed amount is $2,500 and the allowed is $1,276.66. The coinsurance is $254.53.  
January 30, 2023: Billed amount is $2,500 and the allowed is $1,276.66. The coinsurance is $254.53. 
January 31, 2023: Billed amount is $2,500 and the allowed is $1,276.66. The coinsurance is $254.53. 
February 01, 2023: Billed amount is $2,500 and the allowed is $1,276.66. The coinsurance is $254.53. 
February 01, 2023: Billed amount is $285 and the allowed amount is $83.62. The coinsurance is $16.72.  
 
$395.48 + $254.43 + 98.72 + $125.10 + $13.44 + $13.44 + $13.44 + $13.44 + $13.44 + $13.44 + $13.44 + 
$13.44 + $13.44 + $13.44 + $254.53 + $254.53 + $254.53 + $254.53 + $16.72 = $2,043.07. Therefore, results 
in the total cost sharing amount of $2,043.07.  
 
You have been asked to pay a 20% coinsurance for radiation therapy. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies 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. Therefore, we decided that the Plan does not have 
to waive the coinsurance for radiation therapy on January 23, 203, to February 01, 2023.