Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy visits on December 01, 
2022, to January 17, 2023. 
 
You asked the Plan to waive the copayment for radiation therapy visits. You say that you are appealing the 
copays because you feel the treatments were medically necessary for your cancer. 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 $150 
copayment for diagnostic and therapeutic radiology services per outpatient facility visit. Covered services 
include but are not limited to radiation (radium and isotope) therapy including technician materials and 
supplies. The provider billed in the fowling amounts:  
 
Date of Service: 12/1/2022, charge amount: $1946, allowed amount: $74.08, copay assessed: $74.08.  
Date of Service: 12/6/2022, charge amount: $715, allowed amount: $34.30, copay assessed: $34.30. 
Date of Service: 12/6/2022, charge amount: $10,118, allowed amount: $276.25, copay assessed: $115.70. 
Date of Service: 12/7/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 12/8/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 12/9/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 12/14/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 12/16/2022, charge amount: $838, allowed amount: $34.30, copay assessed: $34.30. 
Date of Service: 12/16/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 12/19/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 12/20/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 12/22/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 12/23/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 12/26/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 12/27/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 12/28/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 12/29/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 12/30/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 12/14/2022, charge amount: $3,201, allowed amount: $118.70, copay assessed: $118.70. 
Date of Service: 01/02/2023, charge amount: $918, allowed amount: $34.30, copay assessed: $34.30. 
Date of Service: 01/02/2023, charge amount: $3,478, allowed amount: $122.63, copay assessed: $115.70. 
Date of Service: 01/03/2023, charge amount: $3,478, allowed amount: $122.63, copay assessed: $122.63. 
Date of Service: 01/04/2023, charge amount: $3,478, allowed amount: $122.63, copay assessed: $122.63. 
Date of Service: 01/06/2023, charge amount: $3,478, allowed amount: $122.63, copay assessed: $122.63. 
Date of Service: 01/09/2023, charge amount: $3,478, allowed amount: $122.63, copay assessed: $122.63. 
Date of Service: 01/10/2023, charge amount: $918, allowed amount: $34.30, copay assessed: $34.30. 
Date of Service: 01/10/2023, charge amount: $3,478, allowed amount: $122.63, copay assessed: $115.70. 
Date of Service: 01/11/2023, charge amount: $3,478, allowed amount: $122.63, copay assessed: $122.63. 
Date of Service: 01/12/2023, charge amount: $3,478, allowed amount: $122.63, copay assessed: $122.63. 
Date of Service: 01/13/2023, charge amount: $3,478, allowed amount: $122.63, copay assessed: $122.63. 
Date of Service: 01/16/2023, charge amount: $3,478, allowed amount: $122.63, copay assessed: $122.63. 
Date of Service: 01/17/2023, charge amount: $918, allowed amount: $34.30, copay assessed: $34.30. 
Date of Service: 01/17/2023, charge amount: $3,478, allowed amount: $122.63, copay assessed: $115.70. 
 
The total charged amount is $99,443 and total allowed amount is $3,532.56, and the total cost sharing amount 
is $3,348.22.  
 
You have been asked to pay a $150 copayment for each radiation therapy visit. 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. However, since the allowed amount is less than the 
standard copayment, you only owe a total cost sharing amount of $3,348.22. Therefore, we decided that the 
Plan does not have to waive the copayment for radiation therapy visits on December 01, 2022, to January 17, 
2023.