Shepard v. Shalala

No. 3:93CV2061 (AHN) (D. Conn. Mar. 2, 1995) ; Clearinghouse Number: 50598

Description

Medicare Claimant Entitled to Coverage for Hospitalization Pending Diagnosis of Knee Pain

Abstract

The magistrate has held that plaintiff, an 86-year-old woman with dementia, arthritis, osteoporosis, symptoms of Parkinson’s disease, and incontinence, was entitled to Medicare coverage for a five-day hospitalization. Plaintiff had experienced pain in her right knee of unknown origin that made it impossible for her to walk. Doctors at the hospital suspected that she had fractured her leg, but they needed to conduct further tests to determine the source of the pain; they admitted her to the hospital. Plaintiff’s claim for Medicare coverage for the hospitalization was denied, and she appealed. Finding that plaintiff had not needed inpatient hospital services, an administrative law judge (ALJ) affirmed the denial of coverage. On appeal, plaintiff argued that the ALJ had not considered her overall condition and had failed to apply the Medicare law and regulations properly. The magistrate found that the ALJ failed to accord proper weight to plaintiff’s treating physician’s opinion. The magistrate also found that plaintiff’s hospitalization was appropriate until diagnostic testing could conclusively determine the cause of her knee pain. Accordingly, the magistrate recommended that the ALJ’s decision should be reversed.

Additional Information

Attorney Information
Plaintiff represented by Edward Dale, Legal Assistance to Medicare Patients, 872 Main St., Willimantic, CT 06226, (203) 423-2556.
Docket Date
1995-03-02 00:00:00+00:00

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