Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral AFOs to be provided by an out-of-network provider.
You asked the Plan to pre-approve addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint (L2210x4), ankle foot orthosis, plastic with ankle joint, custom fabricated (L1970x2), addition to lower extremity orthosis, soft interface for molded plastic, below knee section (L2820x2), addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only (L2330x2) from an out-of-network provider. You say that you the AFOs you received from the in-network provider are poor quality and continues to cause you pain and discomfort. The Plan denied your request. The Plan says the in-network provider has provided a resolution and will do another brace evaluation.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers. The provider at issue in this case is not a network provider with the Plan. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the AFOs with the out-of-network provider. Our reviewer says that after careful review of the enclosed information and the pertinent guidelines for this case, it is my opinion that the in network durable medical equipment (DME) supplier will be able to fix the issue with the lower extremity orthoses. Our physician reviewer found the medical documentation does support that the in-network DME supplier admits that they incorrectly interpreted the physician's prescription concerning the AFOs and would fix to meet the prescription issued by the podiatrist. The in-network supplier is obligated to start from the beginning and create new functional AFOs that are exactly to the specifications of the physician. In essence I believe that they deserve a second chance at creating a new device. Therefore, it is my opinion that the in-network DME supplier will be able to fix the issues with the lower extremity orthoses. I feel that a new custom brace from an out-of-network provider is not medically reasonable or necessary to meet the enrollee's needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint (L2210x4), ankle foot orthosis, plastic with ankle joint, custom fabricated (L1970 x2), addition to lower extremity orthosis, soft interface for molded plastic, below knee section (L2820x2), addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only (L2330x2) have not been met. The Plan has network providers available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint (L2210x4), ankle foot orthosis, plastic with ankle joint, custom fabricated (L1970 x2), addition to lower extremity orthosis, soft interface for molded plastic, below knee section (L2820x2), addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only (L2330x2). Therefore, we decided that the Plan does not have to pre-approve bilateral AFOs to be provided by an out-of-network provider.