Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve podiatrist services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve podiatrist services. You say that you are staying with your eldest son until 
September, and you are asking for an out-of-network approval. You are concerned that if you wait until 
September for treatment your condition will deteriorate. The Plan denied your request. The Plan says the 
services are available in-area, and the requested services are neither urgent nor emergent. 
 
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 podiatrist services. Our reviewer says that the service is not medically 
necessary. Our physician reviewer found After careful review of the enclosed information and the guidelines 
for this case, it is my opinion that the care provided/requested was not medically necessary. It is my opinion that the enrollee could have certainly foreseen requiring the services prior to leaving her service area. Finally, 
with the diagnosis of lower extremity edema, venous stasis dermatitis, and onychomycosis, I do believe that it 
would be medically reasonable to delay the services until September 2022 when the enrollee returns to her 
service area. The above-mentioned diagnoses, including lower extremity edema, stasis dermatitis, and 
onychomycosis are not medically urgent diagnoses that would require immediate care. The Medicare 
guidelines advise that emergency care is defined as when a prudent layperson would believe that without 
immediate medical attention there would be serious jeopardy to his or her health. Furthermore, urgently needed 
services are those needed because of an unforeseen illness or condition. Neither of these definitions hold true 
with this particular patient, suffering from lower extremity edema, venous stasis dermatitis, and 
onychomycosis. In fact, the patient advised the internist in North Carolina that all of these conditions were 
chronic. Therefore, it is my opinion that these services were not urgently or emergently needed and could have 
waited until the patient returned to her home in California. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of podiatrist services 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 pre-approve podiatrist services. Therefore, we decided that the Plan 
does not have to pre-approve podiatrist services to be provided by an out-of-network (OON) provider.