Richey v. Shalala; In re Richey

No. W00CA025 (W.D. Tex. filed Feb. 1, 2000)). ; Clearinghouse Number: 52362

Description

Medicare to Cover Lung Volume Reduction Surgery Because It Was Safe, Effective, and "Reasonable and Necessary"

Abstract

The administrative law judge (ALJ) held that payment for claimant’s lung volume reduction surgery (LVRS) was payable under Medicare part B of title XVIII of the Social Security Act because it was not considered an experimental procedure, had been proven safe and effective, and was "reasonable and necessary" for appellant. The claimant’s bill had to be paid despite a national coverage determination that LVRS generally was not a Medicare-covered service. Doctors determined claimant—with a history of emphysema and disabled for purposes of social security—to be an excellent candidate for LVRS. He had the surgery, which dramatically improved his breathing and functional level. Medicare had ordered that a safety and effectiveness study be performed regarding LVRS but refused coverage of the surgery before receiving the study results. A fair hearing officer affirmed denial of coverage because the surgery was experimental. The ALJ, relying on a Medicare covered issues manual section stating that LVRS was not "generally" covered because of insufficient medical evidence on its safety and effectiveness, found that this indicated that in some cases the surgery would be covered, given that it was generally safe and effective. In this case the indication for LVRS was well documented, as was its safety and effectiveness, in well-known medical journals and by qualified physicians.

Additional Information

Attorney Information
Plaintiff represented by Bruce Bower, Texas Legal Serivces Center, 815 Brazos, Suite 1100, Austin, TX 78701 (512.477.6000); Sally Hart, Center for Medicare Advocacy, 3131 N. Country Club Rd., Ste. 100, Tucson, AZ 85716 (520.327.9547); Gill Deford, Center for Medicare Advocacy, P. O. Box 350, Willimantic, CT 06226 (860.456.7790)
Docket Date
2000-02-01 00:00:00+00:00

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