Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for code A9270. We decided that the Plan does not have to waive the 
copayments for debridement.  
 
You asked the Plan to waive the copayments for debridement (11042 x2) provided on January 18, 2023, and 
February 2, 2023, and to pay for code A9270 provided on January 18, 2023, and February 23, 2023. You say 
that you should not be responsible for these charges. The Plan says that this cost sharing was charged correctly. 
The Plan also says that code A9270 has a status indicator of N which indicates that it is not covered by 
Medicare. 
 
We decided that the Plan has to pay for code A9270.  
 
The Plan follows Medicare rules. Medicare 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. There are no medical records within the casefile. Without the requested clinical 
information, we are unable to determine what this generic code represents, or if the provided services were 
medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. The Plan has not substantiated that the enrollee should be liable for these denied 
codes.  
 
The records show that the A9270 codes in dispute were billed by a contracted provider. The file does not show 
what specific service this generic code is representing, or that the Plan provided notice that the services 
represented by this code would not be covered. Under Medicare rules, this means code A9270 is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for code A9270.  
 
We also decided that the Plan does not have to waive the copayments for debridement. 
 
The Plan follows Medicare rules. 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 $295 copayment for each surgical service provided in an outpatient hospital 
setting. 
 
   
You have been asked to pay $590 ($295.00 x2) for debridement. This item/service falls within the surgical 
services provided in an outpatient hospital setting 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 
copayments for debridement. 
 
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.