One thought on “Medicare & You: End stage renal disease/kidney transplant eligibility & enrollment”

1. The item or service reasonable or necessary and, therefore, covered by
   Medicare…

   See Case No. 13-CV-990 Whitcomb v Sylvia Burwell Secretary of Health &
   Human Services.
   http://www.leagle.com/decision/In%20FDCO%2020150601648/WHITCOMB%20v.%20BURWELL

   A remand sentence-four 42 U.S.C. § 405(g) reverses the Medicare Appeals
   Counsel’s decision and is a “victory for the Plaintiff and terminates the
   litigation”.
   Under Federal Law, a prevailing litigant in a case against the United
   States Government is entitled to recover its attorney fees and costs, when
   the position asserted by the government was not substantially justified. 28
   U.S.C. § 2412. “In the present matter this Court ruling recognizes that the
   government’s refusal to cover a medical device for the management of
   ‪Whitcomb’s diabetes was not supported in law or fact”.

   Not only has a judge in the Medicare Office of Hearings and Appeals found
   coverage for CGM was appropriate, but the District Court of Wisconsin has
   ruled that claims cannot be denied based on the Article stating CGM is
   precautionary and therefore not covered…

   On May 26, 2015, the District Court for the Eastern District of Wisconsin
   ruled that the Secretary of Health and Human Services cannot deny coverage
   of a continuous glucose monitor based on a statement in an Article that
   such monitors are “precautionary.” The case reflects the arduous path that
   Type 1 diabetic Medicare beneficiaries endure while trying to secure
   coverage for a medical device that is considered the standard of care for
   Type 1 diabetics with hypoglycemic unawareness – a device widely deemed
   necessary to prevent life-threatening hypoglycemic events. The Medicare
   beneficiary had sought coverage from United Healthcare’s Secure Horizon’s
   Medicare Advantage Plan. Although United Healthcare covers CGM on a limited
   basis for non-Medicare beneficiaries, it does not cover CGM for Medicare
   beneficiaries.

   Through every phase of the multi-step Medicare administrative appeals
   process, the Plaintiff appealed the denial of a CGM that she got in April
   2011. Although statutory regulations provide that an administrative law
   judge should issue a decision within 90 days of a request for an
   administrative hearing, 231 days passed until the Plaintiff received a
   favorable administrative law judge decision, i.e., February 2013. United
   Healthcare appealed the favorable decision and the Medicare Appeals Council
   reversed the decision asserting that the Medicare contractor’s local
   coverage determination (“LCD”) incorporated a Medicare Article that deemed
   CGM to be “precautionary.” Although Medicare regulations require the
   Council to issue a decision within 90 days of a request for review, the
   Council took approximately six months to render a decision, i.e., August
   2013.

   The District Court, however, found that the LCD did not incorporate the
   Article by reference nor vise versa. Further, the Court noted the
   distinction between LCDs (which indicate whether a device is reasonable and
   necessary) and Articles (which address non-coverage information such as
   coding and payment). The Court reasoned that if a Medicare contractor could
   issue a coverage decision in an Article, it would subvert the LCD
   development process and would undermine Medicare beneficiaries’ ability to
   challenge a non-coverage policy as envisioned by Congress under Section 522
   of BIPA.

   The Court remanded the matter to the Medicare Appeals Council to determine
   the Medicare beneficiary’s need for CGM based on her individual medical
   condition, i.e., without reference to the Article. The case underscores the
   challenges faced by Medicare beneficiaries seeking coverage of a device
   that is the standard of care, and the Office of Medicare Hearings and
   Appeals’ and Council’s failure to meet statutory deadlines, even for
   Medicare beneficiaries.

   The Secretary denying CGM on a one-line sentence that is unsupported in law
   or fact stating the CGM is “precautionary” … Since the majority of
   these life threating hypo-events requiring external assistance for recovery
   would be avoided… Not including the $800+ EMT rescue service and
   transportation fee. “The American Journal of Managed Care say” the costs
   for hypoglycemia visits were $17,564 for an inpatient admission, $1,387 for
   an ER visit.” Doing the math: Costs about $640 million a year.

   Reply