Medicare & You: End stage renal disease/kidney transplant eligibility & enrollment

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Medicare & You: End stage renal disease/kidney transplant eligibility & enrollment

 

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.

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