Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the ultrasounds provided on January 31, 2023, and 
the ECG provided on November 7, 2022. We also decided that the Plan does not have to waive the copayments 
for the sigmoidoscopy procedure, inpatient hospital stay, emergency room visit, specialist office visit, vision 
services, and lab services provided from October 12, 2022, to March 3, 2023.  
 
You asked the Plan to waive the cost share for the items/services. You say that you should not be held 
responsible as these services are from complications during a colonoscopy. The Plan denied your request. The 
Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the coinsurance for the ultrasounds and the ECG.  
 
You have been asked to pay $2.22 for the ECG provided on November 7, 2022. Based on the Plan contract you 
cannot be asked to pay more than $2.18, which is 15% coinsurance of the allowed amount ($14.53 allowed 
amount x 15% = $2.18). You have also been asked to pay $76.73 for an ultrasound provided on January 31, 
2023. Based on the Plan contract you cannot be asked to pay more than $75.42, which is 15% coinsurance of 
the allowed amount ($502.82 allowed amount x 15% = $75.42). You have also been asked to pay $10.29 for an 
ultrasound provided on January 31, 2023. Based on the Plan contract you cannot be asked to pay more than 
$10.11, which is 15% coinsurance of the allowed amount ($67.44 allowed amount x 15% = $10.11).  
These items/services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan has to reduce the coinsurance for the ECG provided on November 7, 2022, 
and the ultrasounds provided on January 31, 2023.  We also decided that the Plan does not have to waive the copayments for the sigmoidoscopy procedure, 
inpatient hospital stay, emergency room visit, specialist office visit, vision services, and lab services. 
 
Date of service Benefit category Code Copayment Copayment 
October 12, 2022 Outpatient surgery, 
including services 
provided at hospital 
outpatient facilities 
45334 $350.00 $350.00 
November 7, 2022 
Emergency care 99283 $90.00 $90.00 
November 18, 2022 Physician/Practitioner 
services, including 
doctors office visits 
92012 $91.69 $40.00 
December 27, 2022 Physician/Practitioner 
services, including 
doctors office visits 
99214 $129.85 $40.00 
January 30, 2023 Physician/Practitioner 
services, including 
doctors office visits 
99214 $94.97 $40.00 
February 14, 2023 Physician/Practitioner 
services, including 
doctors office visits 
99214 $128.30 $40.00 
February 21, 2023 Physician/Practitioner 
services, including 
doctors office visits 
99214 $96.99 $40.00 
November 18, 2022 Vision care 92133 $37.54 $5.73 
November 18, 2022 Vision care 92083 $64.24 $9.80 
October 31, 2022 Outpatient diagnostic 
tests and therapeutic 
services and supplies 
85018 $5.00 $2.37 
October 31, 2022 Outpatient diagnostic 
tests and therapeutic 
services and supplies 
85014 $5.00 $2.37 
November 3, 2022 Outpatient diagnostic 
tests and therapeutic 
services and supplies 
85018 $5.00 $2.37 
November 3, 2022 Outpatient diagnostic 
tests and therapeutic 
services and supplies 
85014 $5.00 $2.37 
November 22, 2022 Outpatient diagnostic 
tests and therapeutic 
services and supplies 
85025 $5.00 $5.00 
November 27, 2022 Outpatient diagnostic 
tests and therapeutic 
services and supplies 
85025 $5.00 $5.00 November 28, 2022 Outpatient diagnostic 
tests and therapeutic 
services and supplies 
82728 $5.00 $5.00 
January 31, 2023 Outpatient diagnostic 
tests and therapeutic 
services and supplies 
85610 $5.00 $4.29 
January 9, 2023 Outpatient diagnostic 
tests and therapeutic 
services and supplies 
85027 $5.00 $5.00 
March 2, 2023 Outpatient diagnostic 
tests and therapeutic 
services and supplies 
85610 $5.00 $4.29 
March 3, 2023 Outpatient diagnostic 
tests and therapeutic 
services and supplies 
80053 $5.00 $5.00 
October 19, 2022, to 
October 28, 2022 
Inpatient hospital 
care 
 $5.00 $1,725 
 
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 copayments for the sigmoidoscopy procedure, inpatient 
hospital stay, emergency room visit, specialist office visit, vision services, and lab services. 
 
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.