Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a comprehensive electrophysiological 
procedure provided on March 14, 2023, to March 15, 2023. 
 
You asked the Plan to reduce the cost share for an electrophysiological procedure. You say that you should 
only have been charged a $300 copayment. 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 
copayment for Medicare-covered lab services. Your contract with the Plan also clearly says that you must pay a 
$20 copayment for Medicare-covered non-routine diagnostic tests and procedures. Your contract with the Plan 
also clearly says that you must pay 20% coinsurance for in-network Medicare-covered therapeutic radiology 
services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for in-network 
Medicare-covered prosthetic device and related supplies. Your contract with the Plan also clearly says that you 
must pay 20% coinsurance for in-network covered Medicare Part B drugs. 
 
You have been asked to pay a $8.84, which is less than the standard copayment for laboratory services. You 
have also been asked to pay a $20 copayment for the echocardiogram. These items/services fall 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.  
 
You have also been asked to pay 20% coinsurance for the diagnostic tests and radiology services. These 
items/services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 
You have also been asked to pay 20% coinsurance for the prosthetic device and related supplies. These 
items/services fall within the prosthetic device and related supplies benefit category. You have also been asked 
to pay 20% coinsurance for Medicare Part B drugs. These items/services fall within the Medicare Part B 
prescription drugs benefit category. 
 
Date of Service Item Allowed Amount 20% Coinsurance 
March 14, 2023 Pharmacy $1.70 $0.34 
March 14, 2023 Med/Surg supplies $43.01 $8.60 
March 14, 2023 Med/Surg supplies $387.94 $77.59 
March 14, 2023 Med/Surg supplies $87.55 $17.51 
March 14, 2023 Pharmacy $1.70 $0.34 
March 14, 2023 Pharmacy $3.54 $0.71 
March 14, 2023 Pharmacy $1.70 $0.34 
March 14, 2023 Pharmacy $2.28 $0.46 
March 14, 2023 Med/Surg supplies $855.44 $171.09 
March 14, 2023 Pharmacy $1.70 $0.34 
March 14, 2023 Pharmacy $1.70 $0.34 
March 14, 2023 Med/Surg supplies $209.61 $41.92 
March 14, 2023 Med/Surg supplies $487.90 $97.58 
March 14, 2023 Med/Surg supplies $1,605.48 $321.10 
March 14, 2023 Med/Surg supplies $2,434.06 $486.81 
March 14, 2023 Med/Surg supplies $639.03 $127.81 
March 14, 2023 Med/Surg supplies $2,066.52 $516.63 
 
 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 reduce the cost share for a comprehensive electrophysiological procedure provided on 
March 14, 2023, to March 15, 2023.