Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for durable medical equipment, outpatient 
services, and inpatient hospital stay on January 20, 2022, to December 30, 2022. 
 
You asked the Plan to waive the cost share for durable medical equipment, outpatient services, and inpatient 
hospital stay. 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 20% 
coinsurance for durable medical equipment provider. Covered items include, but are not limited to wheelchairs, 
crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use in the home, 
IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, and walkers. You must pay $350 
copayment per day, days 1 to 5 for inpatient hospital stay. Includes inpatient acute, inpatient rehabilitation, 
long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you 
are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last 
inpatient day. You must pay $275 copayment for advanced imaging services at outpatient hospital. You must 
pay $110 copayment for basic radiological services at outpatient hospital. You must pay $375 copayment for 
nuclear medicine services at outpatient hospital. You must pay $45 copayment for basic radiological services at 
freestanding radiological facility. You must pay $180 copayment for advanced imaging services at primary 
care provider's (PCP's) office, specialist's office and freestanding radiological facility. You must pay $40 
copayment at specialist's office. You must pay $5 copayment for provider and professional services at primary 
care provider's (PCP's) office. You must pay $35 copayment for urgent care center. You must pay $325 
copayment for surgery services at outpatient hospital. The provider billed in the amount of $280 and the 
allowed amount is $42.67 for the service. $42.67 x 20% = $8.53. There were eight dates. 8 x $8.53 = $68.24. 
The provider billed in the amount of $63.22 and the allowed amount is $11.44 for the service. $11.44 x 20% = 
$2.29. The provider billed in the amount of $257.18 and the allowed amount is $97.70 for the service. $97.70 x 
20% = $19.54. The provider billed in the amount of $1,106 and the allowed amount is $36 for the service. $36 
x 20% = $7.20. The provider billed in the amount of $3,963 and the allowed amount is $176.90 for service. 
This is less than the copayment amount. The provider billed in the amount of $1,563.43 and the allowed 
amount is $250.25. This is less than the copayment amount. There is a $350 copayment for inpatient hospital 
stay. There were 4 copayments for $45. 4 x $45 = $180. There were 5 copayments for $40. 5 x $40 = $200. 
There were 3 copayments for $5. 3 x $5 = $15. For all services its, $68.24 + $250.25 + $110 + $375 + $325 + 
$40 + $0.03 + $180 + $180 + $350 + $95 + $200 + $176.90 + $15 + $35 + $2.29 + $19.54 + $7.20 = 
$2,429.45. Therefore, results in the total cost sharing amount of $2,429.45.  
 
You have been asked to pay a $2,429.45 cost share for durable medical equipment, outpatient services, and 
inpatient hospital stay. This item/service falls within the durable medical equipment (DME) and related 
supplies, inpatient hospital care, outpatient diagnostic tests and therapeutic services and supplies and 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. Therefore, we decided that the Plan does not have to waive the cost share for durable medical 
equipment, outpatient services, and inpatient hospital stay on January 20, 2022, to December 30, 2022.