Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve continued care with an out-of-network provider.

You asked the Plan to pre-approve continued care with an out-of-network provider. You say that the requested continued care with an out-of-network provider is medically necessary. The Plan denied your request. The Plan says that the requested continued care with an out-of-network provider is not medically necessary.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care.

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 for continued care with an out-of-network provider. Our reviewer says that the requested continued care with an out-of-network provider is medically necessary. Our physician reviewer found at issue is whether treatment with an out of network provider for the enrollee is a covered service under Medicare rules. The rules say that a Medicare Advantage (MA) organization may specify a network of providers from whom enrollees may obtain services. The MA must establish primary care physicians (PCP) from which the enrollee may select. MA organizations offering coordinated care plans must ensure continuity of care and integration of services through arrangements with contracted providers. This includes services available through contracting or non-contracting providers in the area serviced by the MA plan including nursing home and community-based services. Note that under Medicare rules, continuity of care is based on whether or not the enrollee is currently receiving any active treatment of the enrollee's condition, such that transferring his/her care and medical management to another provider would be medically inappropriate and/or contraindicated at this time.

In this case, the enrollee has refractory focal epilepsy who has been seizure free but has developed tremors as a result of treatment. She is actively undergoing increases in her topiramate to be able to wean valproic acid at a rate of 50mg/day/week. The enrollee is scheduled for a visit in three months from January 2021. The taper is still in effect. The enrollee is receiving active treatment. The elements of the coverage determination are satisfied. The requested service is recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued care with an out-of-network provider have been met. Therefore, we decided that the Plan has to pre-approve continued care with an out-of-network provider.

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.