Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental pneumatic appliance for use with pneumatic 
compressor, full leg with calibrated gradient pressure (E0667, E0650) provided on July 23, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a segmental pneumatic appliance for use with pneumatic compressor, full leg 
with calibrated gradient pressure. You say that the patient was referred for the approved pneumatic 
compression device treatment under "emergency care" with diagnosed Lymphedema.  You also say that the 
enrollee was in emergent need of a gradient pneumatic sequential compression device for the treatment of 
chronic lymphedema. The Plan denied your request. The Plan says the service provided was by a non-
participating provider and was not authorized by the Plan. The Plan also says the records do not reveal any 
medically urgent or emergent services. The Plan also says that they had network providers available to perform 
the services at issue in the appeal. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
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 pay for a segmental pneumatic appliance for use with pneumatic compressor, full leg 
with calibrated gradient pressure. Our reviewer says that this does not meet criteria. Our physician reviewer 
found that the Plan advises that with limited exceptions, members of the Plan must use network providers to get 
medical care and services. The only exceptions are emergencies, urgently needed care when the network is not 
available, out of area dialysis services, and in cases in which the Plan authorizes the use of out-of-network 
providers. The medical documentation does not support that this patient received Plan authorization to utilize 
this out-of-network provider for the segmental pneumatic compression treatment for the lower extremity 
lymphedema. Furthermore, the documentation (the Plan argument) advises that the Plan does indeed possess 
in-network providers that are available to perform the services at issue in this appeal. Therefore, it is my 
opinion that the segmental pneumatic compression treatment for this patient's lower extremity lymphedema 
does not meet the guidelines for medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a segmental pneumatic appliance for use with pneumatic compressor, full leg 
with calibrated gradient pressure have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for a segmental pneumatic appliance for use with pneumatic 
compressor, full leg with calibrated gradient pressure. Therefore, we decided that the Plan does not have to pay 
for a segmental pneumatic appliance for use with pneumatic compressor, full leg with calibrated gradient 
pressure (E0667, E0650) provided on July 23, 2021, by an out-of-network (OON) provider.