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A Success Story with Medicare!
Some time back, Carol Enters submitted a chronicle titled, Lymphedema - The best kept secret in the World of Cancer. (If you would like to read her story again click here)
"NOTICE OF DECISION" - Office of Hearings and Appeal
Her accounting of her experience is all to familiar with far too many patients. Where one can find comfort in numbers, it also reflects the incredible neglect when so many can have the same frustrations and not receive the care and attention so desperately needed.
Carol's efforts to raise awareness and fight for Medicare acknowledgment and coverage for care was recently rewarded on May 2, 2000!
Medicare originally denied her claim submission for payment back in 1998 for her ReidSleeve. She refused to except this denial and was determined to take on Medicare and not stop until she won. We were so excited to learn of her victory, albeit almost 2 years later!
With Carol's permission, we are posting some excerpts from the Appeal decision.
"This decision is Fully Favorable to You. Your Medicare contractor will process the decision and send you a letter about your benefits.
This case is before the Administrative Law Judge upon a request for a hearing. The beneficiary, Carol Enters, received a custom-made ReidSleeve with a gauge. The carrier denied approval for the device, citing the fact that Medicare does not pay for ReidSleeves when it is used with a lymphedema pump. This decision was appealed asserting that the ReidSleeve was not used in conjunction with a pump. It was explained that the custom made compression device replaced the need for a pump."
The notice from Medicare goes on to state that there had been a previous hearing and the denial was upheld, however the denial reasons then changed. In this hearing, Medicare then decided to deny coverage based on their determination that the ReidSleeve "was not considered durable medical equipment (DME) and was not a covered benefit by Medicare, Part B."
Another appeal hearing was then requested and subsequently granted to be heard with a Administrative Law Judge.
The general issue was whether payment may be made under Part B of tittle XVIII of the Social Security Act.
The specific issue was whether the equipment as issue is covered under section 1861(n) and (s)(6) of the Act and Health Care financing administration (HCFA) regulations 42 CFR sections 410.38 and 414.202.
The treating physician for Carol described in writing the medical history and treatment for breast cancer that ultimately resulted in lymphedema. He gave an accounting of her previous treatments for lymphedema and the marked improvement she exhibited when ultimately utilizing the ReidSleeve.
The treating doctor had provided a prescription and certification of medical necessity when the original claim was submitted to Medicare in 1998.
The facility where Carol obtained the ReidSleeve, via written statement for the record, asserted that the ReidSleeve met the definition of DME because it could withstand repeated use, it's function would be for a medical purpose and it was to be used in an individual's home. (These were previously described as requirements in the appeal documents).
Carol then testified that she had benefited from the use of the ReidSleeve. She stated that her swelling had been maintained adequately through use of the device.
The medical advisor present at the hearing in behalf of Medicare testified in his opinion, that the ReidSleeve qualified as DME.
The Administrative Law Judge concluded that the ReidSleeve met the definition of DME as defined above and was indeed a covered benefit by Medicare part B.
"After careful consideration of the entire record, the Administrative Law Judge makes the following findings:"
His findings included; The ReidSleeve met the definition of DME per the appropriate sections aforementioned. The equipment was made to withstand repeated use, was primarily and customarily used to serve a medical purpose, was used in the beneficiary's home and was generally not useful absent a relevant medical condition. He also found that the equipment was reasonable and necessary for the treatment of illness or injury or to improve the functioning of a malformed body member. The equipment issued was cove
red under the provisions of section 1861(n) of the Act and HCFA regulations 42 CFR 414.202.
"It is the decision of the Administrative Law Judge that the ReidSleeve is covered under the provisions of section 1861(n) of the Act and HCFA regulations 42 CFR 414.202. Therefore, the contractor is directed to determine the allowable amount for the equipment and to make the appropriate payment under Part B of title XVIII of the Social Security Act."
We thank Carol for letting us make her story remain public. By more successes being brought to the awareness of the public, it will hopefully encourage others to challenge the system and win.
We are asked on a daily basis if Medicare covers ReidSleeves. We tell people, on the initial claim, it is likely to be denied, however, we do have documented cases of patients who appealed the decision and subsequently won the appeal and received reimbursement. We always let patients know we will assist them to the best of our ability to provide them with knowledge and documentation to appeal Medicare.
It is a time consuming and lengthy process, averaging 18-24 months for final appeals. Our hope, is that in time as more and more patients challenge Medicare, that awareness will rise and perhaps more claims are likely to be paid initially then denied as Medicare acknowledges the acute need to provide coverage for treatment for lymphedema patients.
MORE New Products!
A few eNews editions prior, we announced the OptiFlow CS is now available for the lower extremity. Although we do not have any picture on the website of yet, we will be doing this shortly in addition to adding pictures of our newest product.
The newest addition to our line of products is the OptiFlow CP. This is a slightly more aggressive version of the OptiFlow CS, but still very lightweight and comfortable. It utilizes a slightly denser foam and it extends to the base of the fingers, where the OptiFlow CS goes to the wrist, with a separate hand piece. Both the OptiFlow CS and OptiFlow CP have slightly different characteristics and each may benefit a patient uniquely depending on their needs.
With so many different variations to lymphedema, from preventative garments to treatment for chronic and severe lymphedema, we have found the need to design and provide custom garments to fit the needs of most patients.
We thank all the patients and therapists throughout the years that have been generous with their insight to the unique and special needs of lymphedema patients. This has been insight for our Research and Development department that could not be found anywhere but from the patients that are afflicted and the health care providers that treat lymphedema.