Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the wound care supplies. We decided that the Plan 
does not have to waive the cost share for the radiology services, the office visits, the hospital services, and the 
IV therapy.  
 
You asked the Plan to waive the cost share for the wound care supplies, the radiology services, the office visits, 
the hospital services, and the IV therapy provided from January 26, 2023, to March 20, 2023. You say that you 
should not be held responsible for these charges. The Plan denied your request. The Plan says that this cost 
sharing was charged correctly. 
 
We decided that the Plan has to reduce the coinsurance for the wound care supplies.  
 
You have been asked to pay 50% coinsurance for the wound care supplies. Based on the Plan contract you 
cannot be asked to pay more than 25% coinsurance for the would care supplies provided on January 18, 2023, 
and March 1, 2023. These items fall within the durable medical equipment and related supplies benefit 
category. 
 
Date of Service Item Allowed Amount 25% Coinsurance 
January 18, 2023 Foam dressing $129.10 $32.28 
January 18, 2023 Gelling dressing $168.48 $42.12 
January 18, 2023 Saline solution $17.70 $4.43 
January 18, 2023 Medical tape $4.00 $1 
  Claim Total $79.83 
March 1, 2023 Foam dressing $129.10 $32.28 
March 1, 2023 Saline solution $53.10 $13.28 
  Claim Total $45.56 
 
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 has to reduce the coinsurance for the wound care supplies.  
 We also decided that the Plan does not have to waive the cost share for the radiology services, the office 
visits, the hospital services, and the IV therapy. 
 
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 $30 
copayment for in-network x-rays provided at a specialist office. Your contract with the Plan also clearly says 
that you must pay a $30 copayment for in-network provider professional services at a specialist office. Your 
contract with the Plan also clearly says that you must pay a $150 copayment for in-network advanced imaging 
services provided in a specialist office. Your contract with the Plan also clearly says that you must pay a $40 
copayment for in-network wound care at an outpatient hospital. Your contract with the Plan also clearly says 
that you must pay a $250 copayment for surgery services provided in an outpatient hospital. Your contract with 
the Plan also clearly says that you must pay 50% coinsurance for out-of-network diagnostic procedures and 
tests provided in an outpatient hospital. Your contract with the Plan also clearly says that you must pay 20% 
coinsurance for in-network Medicare Part B covered drugs. 
 
You have been asked to pay a $30 copayment for the x-ray provided on January 26, 2023. This service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also 
been asked to pay a $30 copayment for each specialist office visit provided on February 3, 2023, March 1, 
2023, March 16, 2023, and March 20, 2023. You have also been asked to pay a $150 copayment for the 
magnetic resonance imaging service provided on February 14, 2023. These services fall within the 
physician/practitioner services, including doctor's office visits benefit category. You have also been asked to 
pay a $40 copayment for each wound care service provided on January 26, 2023, February 3, 2023, and 
February 10, 2023. You have also been asked to pay a $250 copayment for the excision procedure provided on 
March 8, 2023. These services fall within the outpatient hospital services 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. 
 
You have been asked to pay $33.27, which is 50% coinsurance of the allowed amount for the office visit 
provided at an outpatient hospital provided on February 13, 2023 (66.54 allowed amount x 50% coinsurance = 
$33.27). This service falls within the outpatient hospital services benefit category. You have also been asked to 
pay $74.88, which is 20% coinsurance of the allowed amount for each IV therapy provided on March 17, 2023, 
March 18, 2023, March 19, 2023, March 20, 2023, March 21, 2023, March 22, 2023, March 23, 2023, March 
24, 2023, March 25, 2023, March 26, 2023, March 27, 2023, March 28, 2023, March 29, 2023, March 30, 
2023, March 31, 2023 ($374.42 allowed amount x 20% = $74.88). These services fall within the Medicare Part 
B prescription drugs 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 cost share for the radiology 
services, the office visits, the hospital services, and the IV therapy. 
 
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.