Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to pre-approve an additional OOA office visit. We decided that the Plan does not have to pre-approve 2 of the additional OOA office visits requested.   You asked the Plan to pre-approve an additional 3 OOA office visits. You say that the enrollee had a transplant OOA for chronic obstructive pulmonary disease. You say that the enrollee needs the requested number of office visits following the sleep study, and she is not currently in New Mexico. You say that the enrollee is in Arizona due to the transplant and the need for follow-up visits after the transplant.  The Plan says that out of network benefits for non-emergent services are not part of the enrollee's benefits. The Plan says that the first 3 visits were approved under the enrollee's transplant benefits.  We decided that the Plan has to pre-approve 1 of the requested OOA office visits.   Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved 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 to pre-approve the OOA office visits. Our reviewer says that the criteria for coverage of 1 additional OOA office visit, beyond what the Plan has already approved, have been met.  Our physician reviewer found that the enrollee had a bilateral lung transplant on July 7, 2021 in Arizona. The enrollee has a history of obstructive sleep apnea (OSA) on positive airway pressure (PAP). The enrollee had persistent hypercarbia after the transplant, and referral to sleep medicine was done to address whether OSA was contributing to that. Bi-level positive airway pressure (BiPAP) pressures have been adjusted. The enrollee needs one additional follow-up visit at the Arizona sleep center to assess the hypercarbia, with an arterial blood gas.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 1 additional OOA office visit have been met. Therefore, we decided that the Plan has to pre-approve 1 additional OOA office visit.   We also decided that the Plan does not have to pre-approve 2 of the requested OOA office visits.  Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved 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 to pre-approve the OOA office visits. Our reviewer says that the criteria for coverage of 2 of the requested OOA office visits have not been met.  Our physician reviewer found that beyond the one additional OOA follow-up visit at the sleep clinic in Arizona, further OOA follow-up visits are not considered medically necessary. Further follow-up can be done within the network when the enrollee returns to the service area.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 2 additional OOA office visit have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 of the requested OOA office visits.  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.