Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy on November 16, 2022, 
to December 21, 2022.  
 
You asked the Plan to waive the coinsurance for radiation therapy. You say that the services should be covered 
in full. 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 each Medicare-covered radiation therapy service. 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: 
 
 On November 16, 2022, the provider billed in the amount of $410 and the allowed amount is $232.31 for the 
service. $232.31 x 20% = $46.46. 
 
On November 16, 2022, the provider billed in the amount of $260 and the allowed amount is $184.78 for the 
service. $184.78 x 20% = $36.96. 
 
On November 17, 2022, the provider billed in the amount of $146 and the allowed amount is $78.56 for the 
service. $78.56 x 20% = $15.71. 
 
On November 17, 2022, the provider billed in the amount of $410 and the allowed amount is $232.31 for the 
service. $232.31 x 20% = $46.46. 
 
On November 22, 2022, the provider billed in the amount of $410 and the allowed amount is $232.31 for the 
service. $232.31 x 20% = $46.46. 
 
On November 23, 2022, the provider billed in the amount of $410 and the allowed amount is $232.31 for the 
service. $232.31 x 20% = $46.46. 
 
On December 14, 2022, the provider billed in the amount of $29 and the allowed amount is $11.98 for the 
service. $11.98 x 20% = $2.40. 
 
On December 14, 2022, the provider billed in the amount of $410 and the allowed amount is $232.31 for the 
service. $232.31 x 20% = $46.46. 
 
On December 15, 2022, the provider billed in the amount of $410 and the allowed amount is $232.31 for the 
service. $232.31 x 20% = $46.46. 
 
On December 15, 2022, the provider billed in the amount of $146 and the allowed amount is $78.56 for the 
service. $78.56 x 20% = $15.71. 
 
On December 15, 2022, the provider billed in the amount of $260 and the allowed amount is $184.78 for the 
service. $184.78 x 20% = $36.96.  
 
On December 16, 2022, the provider billed in the amount of $410 and the allowed amount is $232.31 for the 
service. $232.31 x 20% = $46.46. 
 
On December 19, 2022, the provider billed in the amount of $410 and the allowed amount is $232.31 for the 
service. $232.31 x 20% = $46.46. 
 
On December 20, 2022, the provider billed in the amount of $410 and the allowed amount is $232.31 for the 
service. $232.31 x 20% = $46.46. 
 
On December 21, 2022, the provider billed in the amount of $410 and the allowed amount is $232.31 for the 
service. $232.31 x 20% = $46.46. 
 
For all services it's, $46.46 + $36.96 + $15.71 + $46.46 + $46.46 + $46.46 + $2.40 + $46.46 + $46.46 + $15.71 
+ $36.96 + $46.46 + $46.46 + $46.46 + $46.46 = $572.34. Therefore, results in the total cost shairng amount of 
$572.34. 
 
 
 
 You have been asked to pay a 20% coinsurance for each 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 November 16, 2022, to December 21, 2022.