Doe, In re

(SSA Office of Hearings & App. Nov. 7, 1994) ; Clearinghouse Number: 50584

Description

Medicare Beneficiary Who Was Not Affected by Reconsidered Determination Is Entitled to Hearing on Claim Denial

Abstract

The Appeals Council has remanded to the administrative law judge (ALJ) claimant’s request for a hearing on the denial of Medicare coverage for home health care services provided by a visiting nurse association. Claimant had been denied coverage solely because of technical issues, including lack of documentation and lack of a plan of care, and the visiting nurse association was held solely liable for the cost of claimant’s care. Finding that claimant was not affected by the reconsideration decision, the ALJ denied her request for a hearing. On appeal, claimant argued that the ALJ erred by relying on regulations that govern the Part B fair-hearing process in order to deny a Part A claim before an ALJ. The Appeals Council agreed. The Appeals Council found that 42 C.F.R. § 405.704(b) specifically includes as initial determinations any made with respect to the number of home health visits utilized and that, in this case, determinations of noncoverage were made on 11 skilled nursing and 6 home health aide visits. Accordingly, the Appeals Council directed the ALJ to hold a hearing on claimant’s claim.

Additional Information

Attorney Information
Appellant represented by Julie Salis, Medicare Advocacy Project, Greater Boston Elderly Legal Services, 102 Norway St., Boston, MA 02115, (617) 536-0400.
Docket Date
1994-11-07 00:00:00+00:00

Files

No files available.

Filed under: