Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy on January 02, 2023, to 
January 17, 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 40% 
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: 
 
  For service on January 2, 2023, the provider billed the plan in the amount of $454.00. You are responsible for 
a 40% coinsurance. The coinsurance is $61.74.  
 
For service on January 3, 2023, the provider billed the plan in the amount of $830.00. You are responsible for a 
40% coinsurance. The coinsurance is $112.88. 
 
For service on January 4, 2023, the provider billed the plan in the amount of $830.00. You are responsible for a 
40% coinsurance. The coinsurance is $112.88.  
 
For service on January 4, 2023, the provider billed the plan in the amount of $217.00. You are responsible for a 
40% coinsurance. The coinsurance is $29.51.  
 
For service on January 5, 2023, the provider billed the plan in the amount of $830.00. You are responsible for a 
40% coinsurance. The coinsurance is $112.88.  
 
For service on January 6, 2023, the provider billed the plan in the amount of $571.00. The allowed amount is 
$2,191.00. You are responsible for a 40% coinsurance. The plan paid $1,428.64. A sequestration of $29.15 
applied. The coinsurance is $77.66.  
 
For service on January 6, 2023, the provider billed the plan in the amount of $830.00. You are responsible for a 
40% coinsurance. The coinsurance is $112.88.  
 
For service on January 9, 2023, the provider billed the plan in the amount of $830.00. You are responsible for a 
40% coinsurance. The coinsurance is $112.88.  
 
For service on January 10, 2023, the provider billed the plan in the amount of $830.00. You are responsible for 
a 40% coinsurance. The coinsurance is $112.88. 
 
For service on January 10, 2023, the provider billed the plan in the amount of $454.00. You are responsible for 
a 40% coinsurance. The coinsurance is $61.74. 
 
For service on January 11, 2023, the provider billed the plan in the amount of $830.00. You are responsible for 
a 40% coinsurance. The coinsurance is $112.88. 
 
For service on January 12, 2023, the provider billed the plan in the amount of $830.00. You are responsible for 
a 40% coinsurance. The coinsurance is $112.88.  
 
For service on January 12, 2023, the provider billed the plan in the amount of $799.00. The allowed amount is 
$2,535.73. You are responsible for a 40% coinsurance. The plan paid $1,688.81 A sequestration of $34.46 
applied. The coinsurance is $108. 
 
For service on January 13, 2023, the provider billed the plan in the amount of $830.00. You are responsible for 
a 40% coinsurance. The coinsurance is $112.88.  
 
For service on January 13, 2023, the provider billed the plan in the amount of $571.00. You are responsible for 
a 40% coinsurance. The coinsurance is $77.66. 
 
For service on January 16, 2023, the provider billed the plan in the amount of $830.00. You are responsible for 
a 40% coinsurance. The coinsurance is $112.88.  
 
 
 For service on January 16, 2023, the provider billed the plan in the amount of $454.00. You are responsible for 
a 40% coinsurance. The allowed amount is $1,076.58. The plan paid $773.30. A sequestration of $15.78 
applied. The coinsurance is $61.74. 
 
For service on January 17, 2023, the provider billed the plan in the amount of $830.00. You are responsible for 
a 40% coinsurance. The coinsurance is $112.88. 
 
For all services its, $61.74 + $112.88 + $112.88 + $29.51 + $112.88 + $77.66 + $112.88 + $112.88 + $112.88 
+ $61.74 + $112.88 + $112.88 + $108 + $112.88 + $77.66 + $112.88 + $61.74 +$112.88 + $112.88 = 
$1,832.61. Therefore, results in the total cost shairng amount of $1,832.61. 
 
You have been asked to pay a 40% 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 January 02, 2023, to January 17, 2023.