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UPDATE: THIS FILE LAST EDITED 1-2005

Medicare

AT DENIALS

- AT = ASSISTIVE TECHNOLOGY

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A PUBLICATION FROM THE...

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.....ALL RIGHTS RESERVED

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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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FOLLOWING ARE OFFICIAL EVALUATIONS REGARDING AT-COVERAGE UNDER MEDICARE. THE FIRST REPORT IS ABOUT CCTV ELECTRONIC MAGNIFIERS AND THE SECOND IS ABOUT OCR READING APPLIANCES.

May, 1997

Dear XXXXX X. XXXXXX:

The Center for Health Dispute Resolution (CHDR) is under contract with the Health Care Financing Administration (HCFA) to complete the reconsideration review of determinations made by prepaid health plans regarding its Medicare members. We are reviewing cases in which the health plan has denied payment or approval of medical services. We have received the case file for the above referenced Medicare member.

There are certain rules that apply to Medicare members of a prepaid health plan. One of them is that all covered health care must be obtained through the health plan. There are four exceptions: 1) for an emergency either inside or outside of the plan's service area; 2) for urgently needed care outside of the plan's service area; 3) for services that the plan approved in advance; or, 4) for benefits covered by Medicare that the plan refused to provide. In other cases the health plan is not required to pay the Medicare beneficiary or the provider of services.

We have reviewed the documents available to us in this case. This review was conducted in accordance with the regulations governing Medicare appeal procedures under Section 417.620(b)(2) of Title 42 of the Code of Federal Regulations.

Based upon that review, we are upholding the Health Plan's denial of coverage for a CCTV electronic magnifier. CHDR finds that Kaiser Foundation Health Plan is not responsible for authorizing coverage for a CCTV.

On 11-25-96, the Health Plan issued an initial denial for coverage of a CCTV. The reason for this denial is that a CCTV is considered to be a low vision aid which is not a covered item. An appeal was requested on 12-16-96, and the denial was upheld on 1-15-97, which resulted in the case being forwarded to CHDR for review. However, the case was not received until 5-12-97.

The Medicare Durable Medical Equipment Regional Carriers Manual, Region D, page IX-45, states "Low vision aids are non covered items. These aids are used to maximize residual vision rather than replace "all or part of an internal body organ" and therefore do not meet the definition of a prosthetic device."

CHDR review has determined that a CCTV electronic magnifier is a low vision aid which is excluded from Medicare coverage, as established above. The appeal states that a CCTV should be covered because in 1994 an Administrative Law Judge with the Social Security Administration overturned a denial for coverage of a CCTV. Although the Judge may have ruled that a CCTV should be covered, a determination handed down by an Administrative Law Judge does not set precedent that will change the Medicare guidelines for coverage of a particular item. There is no doubt that this device would be useful. However, the Health Plan cannot be held responsible for coverage of an item that is expressly excluded from Medicare coverage.

Therefore, CHDR has determined that Kaiser Foundation Health Plan is not responsible for authorizing coverage for a CCTV.

"You Have the Right to Further Appeal"

You have the right to further appeal if you do not agree with this decision. Administrative Law Judges (ALJ), of the Social Security Administration, hear the appeals if the ALJ determines that the amount in question is $100 or more.

You must request a hearing within 60 days of the date of this letter. If you choose to do so, you may write to this office. You may also request a hearing by sending your request and a copy of this letter to the health plan, a Social Security Office, or, if you are a railroad retiree, to the Railroad Retirement Board.

"If You Want Help With Your Appeal"

You can have a friend, lawyer or someone else help you with your appeal. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security Office has a list of groups that can help you with your appeal.

If you do not file for a hearing within 60 days, this determination is final and binding unless there is cause for reopening this case under regulations 405.750 and 417.638 of Title 42 of the Code of Federal Regulations.

Sincerely,

THE CENTER FOR HEALTH DISPUTE RESOLUTION

Judith M. Feldt, Project Director

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February, 1999

Dear XXXXX X. XXXXXX:

The Center for Health Dispute Resolution (CHDR) is under contract with the Health Care Financing Administration (HCFA) to complete the reconsideration review of determinations made by Medicare + Choice Organizations (M+COs) regarding their Medicare enrollees. CHDR reviews cases in which an M+CO has denied payment or approval of medical services. CHDR has received the case file for the above referenced Medicare enrollee.

There are certain rules that apply to Medicare enrollees of an M+CO. The general rule concerning health care services is that Medicare enrollees must obtain all covered health care services through their M+CO. There are four exceptions to this rule: 1) for an emergency either inside or outside of the M+CO's service area; 2) for urgently needed care; 3) for services that the M+CO approved in advance; or, 4) for medically necessary services which are covered by Medicare that the M+CO refused to provide.

CHDR has reviewed the documentation available in this case. The review was conducted in accordance with the regulations governing Medicare appeal procedures found at section 422.582 of Title 42 of the Code of Federal Regulations.

Based upon that review, CHDR is upholding the M+CO's denial of authorization for VERA reading device that you have requested.

On 11/27/98 the M+CO issued a denial of authorization for the requested device. The reason for this determination was that VERA is not a covered Medicare benefit. On 12/I3/98 an appeal was requested and on 1I/21/99 the M+CO upheld its original determination. The case was then forwarded to CHDR for review.

The Social Security Act section 1862(a)(1) excludes from Medicare coverage any expenses incurred for items or services which are not medically necessary and reasonable for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Medicare's Coverage Issues Manual § 60-9 notes the requirements for coverage of durable medical equipment (DME) under Medicare. It defines covered DME as equipment that (1) can withstand repeated use, (2) is primarily and customarily used to serve a medical purpose, (3) generally is not useful to a person in the absence of illness or injury, and (4) is appropriate for use in a patient's home.

Medicare Carriers Manual § 2130 defines a prosthetic device as one which replaces all or part of an internal body organ or replaces all or part of the function of a permanently inoperative or malfunctioning organ.

CHDR review of the records submitted by the M+CO indicates that you have requested a Very Easy Reading Device ("VERA"). The VERA device is a computerized scanner that translates scanned text into computerized speech. The Health Plan has declined to authorize the device on the grounds that it is not a covered Medicare benefit. You have argued that the device is either Durable Medical Equipment (DME) or a prosthesis.

CHDR has concluded that the device is neither durable medical equipment nor prosthesis. The device is not DME because it does not primarily serve a medical purpose because it does not contribute to the reversing or retarding of a disease process. Similarly, the device is not a prosthetic because it does not replace all or part of an internal body organ nor does it replace all or part of the function of a permanently inoperative or malfunctioning organ. You suffer from a disease that has affected the functioning of your retina. The function of the retina is to translate light impulses into neurological signals that can be understood by the brain as visual images. The VERA device translates light reflected from text into electronic signals which are then translated by a computer into sounds. In doing so, the device enables your auditory sense to substitute for lack of vision. The device, however, does not functionally substitute for the eyes because it does not lead to the formation of visual images. Medicare has previously decided a similar question with regard to the white cane often used by individuals with little or no vision. The white cane is not a covered Medicare benefit even though to the extent that it informs its user of the landscape, it is a substitute for the eye.

Consequently, CHDR has concluded that VERA does not meet the definition of DME as provided in Coverage Issues Manual § 60-9 and does not meet the definition of a prosthetic found in Medicare Carriers Manual § 2130. In addition, the device is not medically necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member and is therefore excluded from Medicare coverage under section 1862(a)(1) of the Social Security Act.

CHDR has determined, therefore, that the Health Plan is not required to authorize or pay for the Vera reading device you have requested.

"You Have the Right to Further Appeal"

You have the right to further appeal if you do not agree with this decision. Administrative Law Judges (ALJ), of the Social Security Administration, hear the appeals if the ALJ determines that the amount in question is $100 or more.

You must request a hearing within 60 days of the date of this letter. If you choose to do so, you may write to this office. You may also request a hearing by sending your request and a copy of this letter to the M+CO, a Social Security Office, or, if you are a railroad retiree, to the Railroad Retirement Board.

"If You Want Help With Your Appeal"

You can have a friend, lawyer or someone else help you with your appeal. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who will not charge you for their services unless you win your appeal.

If you do not file for a hearing within 60 days, this determination is final and binding unless there is cause for reopening this case under sections 405.750 and 422.616 of Title 42 of the Code of Federal Regulations.

Sincerely,

THE CENTER FOR HEALTH DISPUTE RESOLUTION

Lloyd F, Gerbush, Review Coordinator

Medicare HMOICMP Reconsideration Project

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