Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient hospital care, an ambulance 
transportation, an office visit, an ultrasound, and the hospital services provided from June 13, 2023, to June 30, 
2023.  
 
You asked the Plan to waive the cost share for the inpatient hospital care, an ambulance transportation, an 
office visit, an ultrasound, and the hospital services. You say that you should not have any out-of-pocket costs. 
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. Your 
contract with the Plan says that there is a $800 deductible which applies to inpatient hospital care. Your 
contract with the Plan also clearly says that you must pay 10% of the approved amount for inpatient hospital 
care. The annual deductible applies. Your contract with the Plan also clearly says that you must pay 10% of the 
approved amount for ambulance services. The annual deductible applies. Your contract with the Plan also 
clearly says that you must pay 10% of the approved amount for doctor and other health care provider services. 
The annual deductible applies. Your contract with the Plan also clearly says that you must pay 10% of the 
approved amount for diagnostic tests. The annual deductible applies. Your contract with the Plan also clearly 
says that you must pay 10% of the approved amount for hospital services. The annual deductible applies. 
 
You have been asked to pay $76.56 which is less than 10% of the allowed amount for the inpatient hospital 
care provided on June 13, 2023. You have also been asked to pay 10% coinsurance of the allowed amount for 
the inpatient hospital care provided from June 13, 2023, to June 20, 2023. These items/services fall within the 
inpatient hospital care benefit category. You have also been asked to pay 10% coinsurance of the allowed 
amount for the ambulance transportation provided on June 13, 2023. This item/service falls within the 
ambulance services benefit category. You have also been asked to pay 10% coinsurance of the allowed amount 
for the office visit provided on June 30, 2023. This item/service falls within the doctor and other health care 
provider services benefit category. You have also been asked to pay 10% coinsurance of the allowed amount 
for the ultrasound provided on June 15, 2023. This item/service falls within the diagnostic tests benefit 
category. You have also been asked to pay 10% coinsurance of the allowed amount for the coronary artery 
catheter placement provided on June 15, 2023, and the debridement procedure June 20, 2023. These 
items/services fall within the hospital services benefit category. 
 
Date of Service Item Allowed Amount 10% Coinsurance 
June 13, 2023 Ambulance transportation $1,486.09 $148.61 
June 13, 2023 Initial inpatient hospital care $170.38 $17.04 
June 14, 2023 Initial inpatient hospital care $170.38 $17.04 
June 14, 2023 Subsequent hospital care $116.91 $11.69 
June 15, 2023 Subsequent hospital care $116.91 $11.69 
June 15, 2023 Ultrasound $14.09 $1.41 
June 15, 2023 Artery catheter placement $402.24 $40.22 
June 16, 2023 Discharge management services $112.09 $11.21 
June 20, 2023 Transitional care services $307.31 $30.73 
June 20, 2023 Debridement procedure $163.00 $16.30 
June 30, 2023 Office visit $279.00 $27.90 
 
You have also been asked to pay $157.34 toward your deductible for the inpatient hospital care provided on 
June 13, 2023. You have also been asked to pay $20.70 toward your deductible for the inpatient hospital care 
provided on June 14, 2023. You have also been asked to pay $27.27 toward your deductible for the inpatient 
hospital care provided on June 20, 2023. The items or services you asked the Plan to waive the cost share for 
fall within the inpatient hospital care benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $800 deductible which applies to inpatient hospital care. This cost 
sharing is a contractual obligation that had not been met at the time the inpatient hospital care, an ambulance 
transportation, an office visit, an ultrasound, and the hospital services was received on June 13, 2023, to June 
30, 2023. Therefore, we decided that the Plan does not have to waive the cost share for the inpatient hospital 
care, an ambulance transportation, an office visit, an ultrasound, and the hospital services provided from June 
13, 2023, to June 30, 2023.