Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost sharing for the pharmacy charges, the medical/surgical supplies 
and devices charges, the laboratory charges, the diagnostic radiology charges, the pulmonary function charge, 
the drug charges, the intravenous therapy charges, and the occupational therapy charge. We decided that the 
Plan does not have to waive the cost sharing for the operating room service.  
 
You asked the Plan to waive the cost sharing for the pharmacy charges, the medical/surgical supplies and 
devices charges, the laboratory charges, the diagnostic radiology charges, the pulmonary function charge, the 
drug charges, the intravenous therapy charges, the occupational therapy charge, and the operating room service 
provided on November 2, 2022, to November 3, 2022. You say that the shoulder surgery cost estimator said 
you would only have to pay around $315 for the shoulder surgery. You say you should not be held liable for 
the extra charges. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the cost sharing for the pharmacy charges, the medical/surgical 
supplies and devices charges, the laboratory charges, the diagnostic radiology charges, the pulmonary 
function charge, the drug charges, the intravenous therapy charges, and the occupational therapy 
charge.  
 
The EOC says additional cost sharing only applies during an outpatient hospital observation visit. The records 
do not support that outpatient observation services were billed. This means that only the outpatient surgery 
copayment can be applied. 
 
The Plan says that you must pay $2,019.95 for the pharmacy charges, the medical/surgical supplies and devices 
charges, the laboratory charges, the diagnostic radiology charges, the pulmonary function charge, the drug 
charges, the intravenous therapy charges, and the occupational therapy charge. However, you cannot be asked 
to pay more than $0 for the services. Therefore, we decided that the Plan has to waive the cost sharing for the 
pharmacy charges, the medical/surgical supplies and devices charges, the laboratory charges, the diagnostic 
radiology charges, the pulmonary function charge, the drug charges, the intravenous therapy charges, and the 
occupational therapy charge.  
 
We also decided that the Plan does not have to waive the cost sharing for the operating room service. 
 
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 $275 
copayment for the operating room service.  The Plan has charged you a $252.59 copayment which is less than 
the standard copayment amount. Therefore, we decided that the Plan does not have to waive the cost sharing 
for the operating room service. 
 
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.