In re Doe

No. 000-42-2148 (SSA Office of Hearings & App. Apr. 18, 1996). ; Clearinghouse Number: 51573

Description

Medicare Ordered to Pay Physician’s Customary Charge for Jaw Replacement

Abstract

The administrative law judge (ALJ) has held that the physician’s customary charge for a jaw replacement is reasonable in light of the unusual circumstances of this case which required additional time, effort, and expense. Beneficiary had undergone extensive oral and facial reconstructive surgery following a car accident. The surgery failed, necessitating a total jaw replacement. The physician noted that beneficiary’s case was far more complex than average. Medicare approved the procedure but at a significantly lower rate of payment than the physician’s charge. Expert testimony showed that the physician’s actual and customary charge was comparable to or less than the prevailing charges. The ALJ ordered Medicare to make appropriate payment.

Additional Information

Attorney Information
Appellant represented by Rural Legal Services of Tennessee, P.O. Box 5209, Oak Ridge, Tenn. 37831.
Docket Date
1996-04-18 00:00:00+00:00

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