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UPDATE: THIS FILE LAST EDITED 12-2005

Medicare

AT UPGRADE

- AT = ASSISTIVE TECHNOLOGY

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A PUBLICATION FROM THE...

SIGHT LOSS

INFORMATION

DETECTIVE

.....ALL RIGHTS RESERVED

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SHOULD THE READER WANT TO SUGGEST ANY ADDITIONS OR CORRECTIONS FOR THIS BULLETIN, PLEASE SEND YOUR IDEAS - GO TO LINK, SEND A MESSAGE, NEAR THE TOP OF THIS WEBPAGE.

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NOTE: THIS INFORMATION IS NOT INTENDED AS AN ENDORSEMENT OR RECOMMENDATION, AND IS PRESENTED SIMPLY AS A CONVENIENCE TO THE READER. BECAUSE OF THE CHANGING AVAILABILITY OF PRODUCTS AND SERVICES, THE COMPLETENESS OF THIS LISTING IS NOT GUARANTEED.

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THE FOLLOWING ABRIDGED REPORT IS FROM THE FEDERAL CENTER FOR HEALTH DISPUTE RESOLUTION AND IS THEIR OVERRULE OF A DURABLE MEDICAL EQUIPMENT (DME) REQUEST DENIED BY THE KAISER HEALTH PLAN. PRODUCT DEFINITIONS - SARA = SCANNING AND READING APPLIANCE - VERA = VERY EASY READING APPLIANCE.

AUGUST, 2005

DEAR XXXXXXXXXXXX,

WE AGREE WITH YOU.

THIS MEANS THE KAISER HEALTH PLAN MUST GIVE YOU THE SARA DEVICE.

TO LEARN MORE ABOUT HOW WE MADE OUR DECISION READ BELOW.

WHAT YOU HAVE TO DO

WE SENT THE KAISER HEALTH PLAN A COPY OF THIS LETTER SO THEY KNOW THEY HAVE TO GIVE YOU A SARA DEVICE. BE SURE THEY DO SO OR YOU MAY HAVE TO PAY THE BILL.

THE KAISER HEALTH PLAN MUST GIVE OR MAKE PLANS TO GIVE YOU THE ITEM OR SERVICE WITHIN 72 HOURS.

IF THE KAISER HEALTH PLAN DOES NOT DO SO WITHIN 72 HOURS CALL YOUR REGIONAL MEDICARE OFFICE.

WHO WE ARE

WE ARE EXPERTS AND MEDICARE HIRED US TO REVIEW THE FILES TO SEE IF YOUR HEALTH PLAN MADE THE CORRECT DECISION.

WE WORK FOR MEDICARE. WE DO NOT WORK FOR YOUR HEALTH PLAN.

JANICE EIDEM

PROJECT DIRECTOR

MEDICARE MANAGED CARE

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WE MADE OUR DECISION ON

1. WE READ ALL THE PAPERS IN YOUR FILE

2. WE CHECK MEDICARE RULES

3. WE CHECK YOUR CONTRACT WITH THE KAISER HEALTH PLAN

TO MAKE OUR DECISION

WE READ ALL THE PAPERS IN YOUR FILE VERY CAREFULLY. WE USE THE MEDICARE RULES AND LOOKED TO SEE IF THE KAISER HEALTH PLAN CORRECTLY FOLLOWED MEDICARE RULES AND REGULATIONS.

MEDICARE RULES SAY THAT YOUR HEALTH PLAN MUST GIVE YOU A SUBSCRIBER AGREEMENT. IT IS YOUR CONTRACT WITH THE HEALTH PLAN AND IS USUALLY CALLED THE EVIDENCE OF COVERAGE OR MEMBER AGREEMENT. WE READ THIS CONTRACT CAREFULLY TO SEE WHAT THE KAISER HEALTH PLAN IS SUPPOSED TO COVER.

MEDICARE RULES

THE RULES SAY THAT HEALTH PLANS MUST PAY FOR A MEDICAL SERVICE OR ITEM IF REGULAR MEDICARE WOULD PAY FOR IT FOR YOU.

YOU CAN FIND THIS RULE AT 42 CFR SECTION 422.101, SUB-SECTION 1862 OF THE SOCIAL SECURITY ACT. IT STATES THAT NO PAYMENT MAY BE MADE UNDER MEDICARE FOR ANY ITEM OR SERVICE WHICH IS NOT REASONABLE AND NECESSARY FOR THE TREATMENT OF A ILLNESS OR INJURY OR TO IMPROVE THE FUNCTIONING OF A MALFORMED BODY MEMBER.

SECTION 280.1 OF THE MEDICARE NATIONAL COVERAGE MANUAL STATES THAT COVERAGE DEPENDS ON WHETHER THE ITEM IS REASONABLE AND NECESSARY FOR THE INDIVIDUAL PATIENT. THE ITEM MUST BE ABLE TO WITHSTAND REPEATED USE - IT COULD NORMALLY BE RENTED AND USED BY MANY PATIENTS. THE ITEM MUST BE PRIMARILY AND CUSTOMARILY USED TO SERVE A MEDICAL PURPOSE. THE ITEM IS GENERALLY NOT USEFUL TO A PERSON IN THE ABSENCE OF ILLNESS OR INJURY AND IS APPROPRIATE FOR USE IN THE HOME.

MEDICARE CARRIERS MANUAL SECTION 2130 DEFINES A PROSTHETIC DEVICE AS ONE THAT REPLACES ALL OR PART OF AN INTERNAL BODY ORGAN OR REPLACES ALL OR PART OF THE FUNCTION OF A PERMANENTLY impaired OR MALFUNCTiONING ORGAN.

IF YOU WANT TO READ THESE MEDICARE RULES YOU CAN GO TO THIS WEBSITE:

WWW.MEDICAREAPPEAL.COM

YOUR HEALTH PLAN CONTRACT SAYS THAT THE HEALTH PLAN MUST PROVIDE THOSE MEDICALLY NECESSARY SERVICES COVERED BY MEDICARE.

THE KAISER EVIDENCE OF COVERAGE, PAGE 41, DEFINES THE DME BENEFIT AS COVERING ARTIFICIAL AIDS THAT REPLACE ALL OR PART OF THE BODY ORGAN OR EXTREMITY. THESE ITEMS MUST BE NON-DISPOSABLE AND APPROPRIATE FOR USE IN THE HOME, ABLE TO WITHSTAND REPEATED USE, MEDICALLY NOT NECESSARY TO A PERSON IN THE ABSENCE OF ILLNESS OR INJURY AND APPROVED FOR COVERAGE UNDER MEDICARE DME GUIDELINES.

OUR DECISION

OUR DECISION IS THAT THE KAISER HEALTH PLAN DOES HAVE TO GIVE YOU A SARA DEVICE. THE CASE FILE SHOWS THAT YOU ARE LEGALLY BLIND AND HAVE BEEN USING A VERA DEVICE WHICH IS UNREPAIRABLE AND CANNOT BE REPLACED WITH THE SAME MODEL. THE ENROLLEE HAS ASKED THAT A SIMILAR DEVICE (A SARA) BE COVERED BY THE HEALTH PLAN. THE HEALTH PLAN HAS DENIED THE REQUEST.

THE VERA IS A DEVICE THAT SCANS A DOCUMENT AND THEN READS THE CONTENTS BACK TO THE ENROLLEE. IN 1999 THE ENROLLEE APPLIED FOR COVERAGE OF VERA AND THE CENTER FOR HEALTH DISPUTE RESOLUTION APPEAL WAS DENIED. A FURTHER APPEAL WAS MADE TO A ADMINISTRATIVE LAW JUDGE.

THIS JUDGE HELD THAT A VERA FOR THIS ENROLLEE MET THE CRITERIA OF THE LEGISLATION AND RULES. THE JUDGE SAID THAT THE EQUIPMENT FALLS WITHIN THE DEFINITION OF DME. THE EQUIPMENT IS REASONABLE AND NECESSARY BASED ON THE CONDITION OF THE ENROLLEE.

THE EQUIPMENT IN THIS CASE QUALIFIES AS A PROSTHETIC DEVICE. THE SARA DEVICE SOUGHT AT THIS TIME BY THE ENROLLEE IS COMPARABLE TO THE VERA DEVICE THAT NEEDS REPLACEMENT. IN AN EFFORT TO MAINTAIN THE CONTINUITY OF CARE AND GIVEN THE HISTORY OF THE ENROLLEE WITH THE ADMINISTRATIVE LAW JUDGE FAVORABLE DECISION ON THIS TOPIC, WE FIND IN THIS CASE THE REQUESTED DEVICE MEETS THE DEFINITION OF DME.

THE EQUIPMENT IS NOT PRIMARILY USEFUL TO A PERSON WITHOUT A ILLNESS AND IT IS REASONABLE AND NECESSARY FOR THIS INDIVIDUAL PATIENT. THE EQUIPMENT CAN WITHSTAND REPEATED USE AND IT IS APPROPRIATE FOR USE IN THE HOME OF THE PATIENT.

IF THE KAISER HEALTH PLAN DOES NOT AGREE WITH OUR DECISION THEY CAN ASK US TO OPEN THE CASE AGAIN. WE ONLY OPEN A CASE AGAIN IF WE BELIEVE THERE WAS A MISTAKE OR THERE IS NEW INFORMATION TO REVIEW. THE HEALTH PLAN HAS TO SHOW US THE MISTAKE AND OR SEND US THE NEW INFORMATION. THIS DOES NOT HAPPEN OFTEN.

IF WE DECIDE TO OPEN YOUR CASE AGAIN WE WILL SEND YOU A LETTER.

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