Medicare Appeals Council (Council) Decisions

In January 2003, the Medicare Appeals Council (Council) initiated the posting of certain significant decisions and actions on the web site of the Departmental Appeals Board (of which it is a component). The following decisions and actions were selected for posting since they involve the adjudication of issues that may be of interest to various stakeholders in the Medicare appeals process. They are searchable as well as indexed by primary topic area. This compendium of Council decisions will be supplemented periodically.

Some Council decisions are carried by WESTLAW (in the Federal Health Law database, identifier FHTH-HHS), a commercial legal research service.

In October 2018, the Council changed the look and format of its decisions, including a different font style and a more simplified layout.

Cases with an asterisk (*) were later appealed to the federal courts. The reader may wish to research any subsequent action by the courts.

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Browse Council Decisions by Topic Area

Cases involving ambulance services, such as destination and medical documentation requirements.

  • In the Case of W.K. [PDF – 26KB] (March 19, 2013) (the beneficiary, not the ambulance company, is responsible for payment when the destination requirements were not met).
  • In the Case of North Country Ambulance [PDF – 50KB] (June 15, 2012) (The documentation supports the conclusion that the medical condition of the beneficiary required ambulance transport).
  • In the Case Midwest Lifeteam (March 18, 2011) (The beneficiary, rather than the supplier, is responsible payment when the services do not meet the criteria under the origin and destination coverage requirements of the regulations).
  • In the Case of Eagle Air Med (March 18, 2011) (A finding that a beneficiary required ground ambulance services versus air ambulance transport is an adverse level of care determination and it is appropriate to consider whether the beneficiary and the appellant are entitled to limitation on liability protection).
  • In the Case of Estate of G.B.R. (December 3, 2010) (The ambulance service furnished to the beneficiary from one trauma center to another met Medicare coverage guidelines because specialized neurological/neurosurgical critical care was unavailable at the hospital to which the beneficiary was originally taken).
  • In the Case of Gold Cross Ambulance (September 29, 2009) (the record contains medical documentation from the beneficiary's physician, in addition to a Physician Certification Statement, that shows the ambulance transportation was medically required).
  • In the Case of D.C. (November 17, 2009) (the evidence fails to show the ambulance services were medically required and when the criteria for coverage are not met, limitation on liability provisions do not apply).

Cases involving coverage for dental and associated services under Medicare Part A and Medicare Part B.

  • In the Case of A.F. (November 12, 2009) (payment for an oral appliance, as an item of durable medical equipment, will not be made for a replacement furnished within five years of the previous covered oral appliance).
  • In the Case of the Estate of W.D. (April 10, 2009) (the evidence shows the hospital services received in connection with a dental surgery are excluded from coverage as the beneficiary was admitted and received treatment for extraction of teeth in a hospital setting as an outpatient).
  • In the Case of A.K. (May 24, 2009) (the record indicates the beneficiary's dental surgery was performed on an outpatient basis in a hospital operating room and the anesthesiology fee is therefore not a Part A inpatient hospital expense).
  • In the Case of A.B. (August 13, 2009) (Medicare coverage for medical services, as opposed to coverage for the dental services, is based on when the hospitalization is required because of the individual's underlying condition and medical status).

Cases involving equipment such as wheelchairs and the documentation requirements for coverage of the equipment.

  • In the Case of D.L. (May 11, 2015) (Council determined Medicare would not cover the OmniPod insulin pods at issue)
  • In the Case of Liberator Medical Supply (May 9, 2014) (Medicare’s consolidated billing and prospective payment law and the applicable CMS manual do not allow a Part B supplier to seek coverage for supplies provided on a date of service when the beneficiary is in a Part A episode, supplier not permitted to bill in advance)
  • In the Case of Zoll Lifecor Corporation [PDF – 27KB] (Aug. 21, 2013) (Medicare coverage for a wearable automatic external defibrillator)
  • In the Case of Cashflow Solutions [PDF – 199KB] (December 20, 2012) (found Medicare coverage appropriate for some pneumatic compression devices at issue).
  • In the Case of S.M. [PDF – 86KB] (December 17, 2012) (diabetic alert dog does not fall within the definition of DME under Medicare Part B).  
  • In the Case of ATG Connecticut [PDF – 23KB] (Dec. 12, 2012) (Medicare coverage for a power articulating foot platform furnished to the beneficiary as part of a power wheelchair)
  • In the Case of AeroCare Holdings [PDF -26.2KB] (Aug 3, 2012) (The Council reversed the ALJ’s decision and found that Medicare would cover the formoterol fumarate inhalation solution refill).
  • In the Case of Cornerstone Prosthetics and Orthotics [PDF – 81KB] (June 19, 2012) (The Council concluded that the appellant provided no basis for entitlement to additional reimbursement for the articulating prosthetic fingers and thumb user unit provided to the beneficiary).
  • In the Case of R.C. [PDF - 85KB] (June 13, 2012) (The medical records do not demonstrate that the beneficiary requires mobility assistive equipment for MRADLs within his home).
  • In the Case of The Scooter Store (May 18, 2012) (The Council found that the medical documentation is insufficient to substantiate the medical necessity for the power wheelchair and accessories, and further stated that the treating physician rule does not apply in the matter before it).
  • In the Case of Chair & Equipment Rentals and Sales (April 13, 2012) (finding the non-covered items payable under section 1879 where the record did not support a finding that the supplier could have been expected to know that the items were excluded from coverage).
  • In the Case of Loyalsock Mobility (April 12, 2012) (the appellant met the documentation requirements along with all other requirements for coverage of the power wheelchair and accessories).
  • In the Case of Home Medi Service, Inc.(September 29, 2011) (The beneficiary may receive a new power wheelchair, without regard to the existence of the previous wheelchair furnished more than five years previously, provided she satisfies the requirements for coverage anew).
  • In the Case of National Seating & Mobility (September 20, 2011) (The power seat elevation system and electrical connecting components at issue and do not meet the definition of durable medical equipment for Medicare coverage).
  • In the Case of Gordian Medical, Inc. d/b/a American Medical Technologies (September 16, 2011) (Contrary to the appellant’s assertions, it is reasonable to assume that long-term care facilities would maintain clinical records detailing wound evaluations and care performed by physicians, nurses, and other treating health care professionals to substantiate the need for the type and quantity of items ordered, as well as for the frequency of use or replacement).
  • In the Case of Advanced Medical Concepts, Inc. (September 13, 2011) (The evidence of record fails to document the beneficiary’s weight gain and is insufficient to demonstrate that the power wheelchair was medically necessary).
  • In the Case of Allied Home Medical, Inc. (July 29, 2011) (The documentation of record does not establish that the beneficiary was unable to self-propel a manual wheelchair and the power wheelchair at issue is not covered by Medicare).
  • In the Case of S.C.S. (January 20, 2011) (The evidence of record fails to show the power standing system device at issue primarily and customarily serves a medical purpose and therefore, regardless of its benefit to the beneficiary, is not a durable medical equipment).
  • In the Case of D.B.C. (November 22, 2010) (The supplier received Medicare payment in error for a power wheelchair and accessories which resulted in an overpayment as the record shows that the beneficiary took physical possession of the wheelchair, at the insistence of the supplier, more than 120 days after the face-to-face physician consult).
  • In the Case of International Rehabilitative Sciences, Inc. (September 22, 2010) (reviewing coverage claims for a durable medical device that is the subject of multiple district court decisions, the Council finds the Maryland district court's decision persuasive in this case and that the Washington district court decision is limited to the facts of those particular cases).
  • In the case of OJ Medtech, Inc. (February 19, 2010) (clinical documentation satisfied the coverage criteria set forth in both the applicable NCD and LCD, and the device furnished to the beneficiary was reasonable and necessary for the treatment of her medical condition).
  • In the case of Affordable Home Care (June 22, 2010) (documentation requirements of LCD for power wheelchairs and accessories do not apply to equipment that is replacement equipment for damaged or destroyed items and that have been determined medically necessary for the Medicare beneficiary).
  • In the case of Extreme Mobility, Inc. (June 22, 2010) (descriptive phase "power-mobility device" was sufficient description of the medical equipment needed based upon beneficiary's health records to satisfy the relevant LCD).
  • In the case of J. D. K. (August 20, 2010) (incorrect billing coding not detrimental to DME claim when the unassigned claim was filed by the beneficiary and the contractor assigned the incorrect billing code).
  • In the Case of Maximum Comfort, Inc.* (June 11, 2003) (the certificate of medical necessity (CMN) submitted by the supplier is insufficient to document the criteria for Medicare coverage and the supplier is required to maintain medical documentation in addition to the CMN).
  • In the Case of Kinetic Concepts Inc. (October 28, 2008) (the checklist forms created by the supplier sufficiently establish medical necessity for continuing coverage during the first four months of treatment in the absence of underlying clinical records as the forms require certifying physicians to provide clinical data in support of the certifications and the forms contain the information required by the local coverage determination to establish medical necessity).
  • In the Case of Kinetic Concepts Inc. (June 5, 2009) (the local coverage determination requires documentation in addition to the supplier created checklist to establish medical necessity beyond four months and must be from an independent provider, case specific, contemporaneous with the beginning of the fifth month, explain the special circumstances necessitating the extended time, and justify the expense to the Medicare program based on the therapeutic benefits to the individual beneficiary).
  • In the Case of BioniCare Medical Technologies, Inc.* (July 13, 2009) (coverage by Medicare for a durable medical device, and related supplies, depends on the device being safe and effective and not experimental; devices categorized by the Food and Drug Administration (FDA) as non-experimental/investigational are eligible for consideration of Medicare coverage but the FDA classification does not qualify the device for automatic coverage; assignment of a HCPCS code does not automatically imply coverage).
  • In the Case of Keeler's Medical Supply (September 21, 2009) (medical evidence documenting the beneficiary's weight gain over a three year period is sufficient to show the beneficiary met the criteria for a heavy duty wheelchair as she exceeded the weight limit for her previously supplied standard wheelchair).
  • In the Case of Hudson Home Health Care (August 12, 2009) (the medical documents, signed by both the beneficiary's physician and physical therapist, is sufficient evidence of the criteria for Medicare coverage of a new lightweight wheelchair).
  • In the Case of Webb Medical Systems (October 27, 2009) (the documents submitted showing the treating physician conducted a full face-to-face examination for the purpose of evaluating the beneficiary's need for a power mobility device contain sufficient evidence of the criteria for Medicare coverage of a wheelchair accessory kit).
  • In the Case of Allied Home Medical, Inc. (October 27, 2009) (a supplier may not dispense a power mobility device to a beneficiary until the supplier has received both the prescription and the supporting documentation to substantiate the medical necessity for the item from the physician).
  • In the Case of C.H. (October 28, 2009) (the adjustable bed and mattress do not meet the definition of durable medical equipment which is equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to an individual in the absence of an illness or injury, and is appropriate for home use).

Cases involving enrollment into Medicare, such as penalties for late enrollment in Medicare Part B.

  • In the Case of D.L. (May 11, 2015) (Council determined Medicare would not cover the OmniPod insulin pods at issue)
  • In the Case of Liberator Medical Supply (May 9, 2014) (Medicare’s consolidated billing and prospective payment law and the applicable CMS manual do not allow a Part B supplier to seek coverage for supplies provided on a date of service when the beneficiary is in a Part A episode, supplier not permitted to bill in advance)
  • In the Case of Zoll Lifecor Corporation [PDF – 27KB] (Aug. 21, 2013) (Medicare coverage for a wearable automatic external defibrillator)
  • In the Case of Cashflow Solutions [PDF – 199KB] (December 20, 2012) (found Medicare coverage appropriate for some pneumatic compression devices at issue).
  • In the Case of S.M. [PDF – 86KB] (December 17, 2012) (diabetic alert dog does not fall within the definition of DME under Medicare Part B).  
  • In the Case of ATG Connecticut [PDF – 23KB] (Dec. 12, 2012) (Medicare coverage for a power articulating foot platform furnished to the beneficiary as part of a power wheelchair)
  • In the Case of AeroCare Holdings [PDF -26.2KB] (Aug 3, 2012) (The Council reversed the ALJ’s decision and found that Medicare would cover the formoterol fumarate inhalation solution refill).
  • In the Case of Cornerstone Prosthetics and Orthotics [PDF – 81KB] (June 19, 2012) (The Council concluded that the appellant provided no basis for entitlement to additional reimbursement for the articulating prosthetic fingers and thumb user unit provided to the beneficiary).
  • In the Case of R.C. [PDF - 85KB] (June 13, 2012) (The medical records do not demonstrate that the beneficiary requires mobility assistive equipment for MRADLs within his home).
  • In the Case of The Scooter Store (May 18, 2012) (The Council found that the medical documentation is insufficient to substantiate the medical necessity for the power wheelchair and accessories, and further stated that the treating physician rule does not apply in the matter before it).
  • In the Case of Chair & Equipment Rentals and Sales (April 13, 2012) (finding the non-covered items payable under section 1879 where the record did not support a finding that the supplier could have been expected to know that the items were excluded from coverage).
  • In the Case of Loyalsock Mobility (April 12, 2012) (the appellant met the documentation requirements along with all other requirements for coverage of the power wheelchair and accessories).
  • In the Case of Home Medi Service, Inc.(September 29, 2011) (The beneficiary may receive a new power wheelchair, without regard to the existence of the previous wheelchair furnished more than five years previously, provided she satisfies the requirements for coverage anew).
  • In the Case of National Seating & Mobility (September 20, 2011) (The power seat elevation system and electrical connecting components at issue and do not meet the definition of durable medical equipment for Medicare coverage).
  • In the Case of Gordian Medical, Inc. d/b/a American Medical Technologies (September 16, 2011) (Contrary to the appellant’s assertions, it is reasonable to assume that long-term care facilities would maintain clinical records detailing wound evaluations and care performed by physicians, nurses, and other treating health care professionals to substantiate the need for the type and quantity of items ordered, as well as for the frequency of use or replacement).
  • In the Case of Advanced Medical Concepts, Inc. (September 13, 2011) (The evidence of record fails to document the beneficiary’s weight gain and is insufficient to demonstrate that the power wheelchair was medically necessary).
  • In the Case of Allied Home Medical, Inc. (July 29, 2011) (The documentation of record does not establish that the beneficiary was unable to self-propel a manual wheelchair and the power wheelchair at issue is not covered by Medicare).
  • In the Case of S.C.S. (January 20, 2011) (The evidence of record fails to show the power standing system device at issue primarily and customarily serves a medical purpose and therefore, regardless of its benefit to the beneficiary, is not a durable medical equipment).
  • In the Case of D.B.C. (November 22, 2010) (The supplier received Medicare payment in error for a power wheelchair and accessories which resulted in an overpayment as the record shows that the beneficiary took physical possession of the wheelchair, at the insistence of the supplier, more than 120 days after the face-to-face physician consult).
  • In the Case of International Rehabilitative Sciences, Inc. (September 22, 2010) (reviewing coverage claims for a durable medical device that is the subject of multiple district court decisions, the Council finds the Maryland district court's decision persuasive in this case and that the Washington district court decision is limited to the facts of those particular cases).
  • In the case of OJ Medtech, Inc. (February 19, 2010) (clinical documentation satisfied the coverage criteria set forth in both the applicable NCD and LCD, and the device furnished to the beneficiary was reasonable and necessary for the treatment of her medical condition).
  • In the case of Affordable Home Care (June 22, 2010) (documentation requirements of LCD for power wheelchairs and accessories do not apply to equipment that is replacement equipment for damaged or destroyed items and that have been determined medically necessary for the Medicare beneficiary).
  • In the case of Extreme Mobility, Inc. (June 22, 2010) (descriptive phase "power-mobility device" was sufficient description of the medical equipment needed based upon beneficiary's health records to satisfy the relevant LCD).
  • In the case of J. D. K. (August 20, 2010) (incorrect billing coding not detrimental to DME claim when the unassigned claim was filed by the beneficiary and the contractor assigned the incorrect billing code).
  • In the Case of Maximum Comfort, Inc.* (June 11, 2003) (the certificate of medical necessity (CMN) submitted by the supplier is insufficient to document the criteria for Medicare coverage and the supplier is required to maintain medical documentation in addition to the CMN).
  • In the Case of Kinetic Concepts Inc. (October 28, 2008) (the checklist forms created by the supplier sufficiently establish medical necessity for continuing coverage during the first four months of treatment in the absence of underlying clinical records as the forms require certifying physicians to provide clinical data in support of the certifications and the forms contain the information required by the local coverage determination to establish medical necessity).
  • In the Case of Kinetic Concepts Inc. (June 5, 2009) (the local coverage determination requires documentation in addition to the supplier created checklist to establish medical necessity beyond four months and must be from an independent provider, case specific, contemporaneous with the beginning of the fifth month, explain the special circumstances necessitating the extended time, and justify the expense to the Medicare program based on the therapeutic benefits to the individual beneficiary).
  • In the Case of BioniCare Medical Technologies, Inc.* (July 13, 2009) (coverage by Medicare for a durable medical device, and related supplies, depends on the device being safe and effective and not experimental; devices categorized by the Food and Drug Administration (FDA) as non-experimental/investigational are eligible for consideration of Medicare coverage but the FDA classification does not qualify the device for automatic coverage; assignment of a HCPCS code does not automatically imply coverage).
  • In the Case of Keeler's Medical Supply (September 21, 2009) (medical evidence documenting the beneficiary's weight gain over a three year period is sufficient to show the beneficiary met the criteria for a heavy duty wheelchair as she exceeded the weight limit for her previously supplied standard wheelchair).
  • In the Case of Hudson Home Health Care (August 12, 2009) (the medical documents, signed by both the beneficiary's physician and physical therapist, is sufficient evidence of the criteria for Medicare coverage of a new lightweight wheelchair).
  • In the Case of Webb Medical Systems (October 27, 2009) (the documents submitted showing the treating physician conducted a full face-to-face examination for the purpose of evaluating the beneficiary's need for a power mobility device contain sufficient evidence of the criteria for Medicare coverage of a wheelchair accessory kit).
  • In the Case of Allied Home Medical, Inc. (October 27, 2009) (a supplier may not dispense a power mobility device to a beneficiary until the supplier has received both the prescription and the supporting documentation to substantiate the medical necessity for the item from the physician).
  • In the Case of C.H. (October 28, 2009) (the adjustable bed and mattress do not meet the definition of durable medical equipment which is equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to an individual in the absence of an illness or injury, and is appropriate for home use).

Cases involving appeal filing requirements as well as legal issues such as the timely submission of evidence and good cause for late filing of an appeal.

  • In the Case of Mass Health (Feb. 27, 2014) (no due process infringement when ALJ denied VTC hearing, but held a telephone hearing instead)
  • In the Case of Vision Quest Industries  [PDF – 20KB] (Dec. 6, 2012) (right to an ALJ hearing)
  • In the Case of King’s Daughter Medical Center [PDF – 151KB] (June 26, 2012) (The Council found that the regulation on which CMS relied in its referral memorandum does not apply in this case and that the ALJ did not err in affording greater weight to the admitting physician’s decision for inpatient admission). 
  • In the Case of Spokane Washington Hospital Company [PDF – 58KB] (June 19, 2012) (The Council declined to review the ALJ’s decision because, contrary to CMS’s assertion, there were no errors of law material to the outcome of the case).
  • In the Case of Nizhoni Health Systems (June 1, 2012) (The Council remanded because the ALJ failed to notify the provider of the home health services at issue of the proceedings at the ALJ level and provide it with an opportunity to participate).
  • In the Case of Eagle Air Medical Corporation (April 12, 2012) (remanding where the beneficiary did not receive notice of the appeals proceeding that took place after the QIC’s review).
  • In the Case of Cashflow Solutions, Inc. (April 6, 2012) (adding claims at the ALJ level that have not been adjudicated at lower appeals levels is prohibited).
  • In the Case of American Home Podiatry (May 20, 2011) (an appellant may not seek a subpoena in order to shift the burden of proof to the contractor).
  • In the Case of A.L. (January 21, 2011) (The beneficiary died after filing a request for hearing before an ALJ.  The appellant has not demonstrated that she is authorized to act on behalf of a proper party, or otherwise has any interest as a substitute party).
  • In the case of C.C. (July 2, 2010) (the unrepresented beneficiary filed a single request for hearing before the ALJ listing five dates of services originally at issue and the record demonstrates it was reasonable for the beneficiary to believe the all the dates of service at issue would be treated as one aggregated appeal).
  • In the Case of International Rehab. Sciences (April 8, 2009) (if a request for claims to be aggregated for an ALJ hearing is based on common issues of law and fact, the claims must arise from similar, but not necessarily identical, fact patterns).
  • In the Case of Philip B. Khourty, M.D. (October 2, 2009) (the appellant submitted evidence of a serious illness in his immediate family as good cause for the untimely filing of his request for hearing before an ALJ).
  • In the Case of Health & Oncology, Inc. (September 21, 2009) (the appellant had good cause for submitting new evidence after the reconsideration by the qualified independent contractor (QIC) as the QIC's decision identified a new issue for the basis of the denial).
  • In the Case of Robert Markman, M.D. (October 21, 2009) (the ALJ did not abuse his discretion in denying the appellant's request for subpoenas).
  • In the Case of Breton L. Morgan, M.D. (November 5, 2009) (an ALJ must identify in a meaningful way the documentation which will be excluded from the record).
  • In the Case of John Handron, Ph.D.* (May 22, 2008) (while section 504 of the Equal Access to Justice Act allows for fees and expenses for administrative proceedings conducted before an ALJ in connection with adversarial Medicare proceedings, the position of the United States must be represented at the ALJ hearing by counsel or otherwise to qualify for payment of attorney fees).
  • In the Case of General Medicine, P.C. (September 6, 2007) (if an ALJ fails to adjudicate claims for which perfected requests for hearing were filed within the 90-day deadline, an appellant may request the claim be escalated to the Council; after receiving the request for escalation, the ALJ has five days to adjudicate the claims, if the ALJ is unable to adjudicate the claims, the appellant must then file a request for escalation with the Council to review the reconsideration decision(s); an appellant has no right to request escalation to the Council when it waived, in writing, the ALJ's adjudication deadline).

Cases involving coverage requirements for home health services such as homebound status and documentation requirements.

  • In the Case of State of New York (March 17, 2016) (the fact that a beneficiary received home health aide services exceeding Medicare's 35-hour limit is not an appropriate basis for denying eligibility and coverage for the first 35 hours of services).
  • In the Case of Delaware Hospice, Inc. [PDF – 66KB] (June 28, 2012) (The ALJ erred in waiving appellant’s liability based upon lack of knowledge because the ALJ failed to comply with the language and instructions contained in CMS Ruling 95-1).
  • In the Case of All Valley Home Health (March 19, 2012) (contrary to the ALJ decision, neither attendance at adult day care nor going to doctor’s appointments disqualifies a beneficiary from being homebound).
  • In the Case of Landmark Home Health Care (August 9, 2011) (The combination of the beneficiary’s condition, age, medical history and limited mobility created a very reasonable potential for serious complications or a change in condition that could require skilled nursing care).
  • In the Case of R.B. o/b/o J.B. (December 17, 2010) (The beneficiary is not homebound as the record indicates she leaves home four days every week to engage in "sheltered workshop" activities (music therapy, games, puzzles, social skills development) at an adult day care center).
  • In the Case of State of Vermont (November 16, 2010) (The fact that the beneficiary was at risk for skin breakdown weighs in favor of, rather than against, the need for skilled observation and assessment by a nurse when the beneficiary's caregivers identified wounds when providing care to the beneficiary).
  • In the Case of Excellent In-Home Care (February 19, 2010) (services provided to two beneficiaries were of the nature of general assessments, ongoing observations and repetitive teaching and were not skilled nursing services and therefore not covered by Medicare).
  • In the Case of G.R. (October 15, 2007) (prior appellate determinations finding a beneficiary to be homebound are afforded great evidentiary weight and the record failed to reveal objective medical evidence that his clinical condition had significantly changed for the dates of service at issue).
  • In the Case of Uphams Home Health Care (September 14, 2009) (a typewritten name does not meet the signature requirement that home health services based upon a physician's verbal order be signed and dated with the date of receipt by the registered nurse or other authorized agency recipient).
  • In the Case of New Jersey Dept. of Human Services (May 22, 2009) (the totality of circumstances surrounding a beneficiary's complicated medical condition justifies the physician's conclusion that she required skilled physical therapy support for maintenance therapy).
  • In the Case of New Jersey Dept. of Human Services (May 4, 2009) (although subcutaneous injections are not generally covered home health skilled nursing services, coverage is appropriate in the instant case as the evidence shows the beneficiary was unable to self-inject due to visual impairment and there is no evidence of another person willing and able to administer the injections).
  • In the Case of Prestige Home Care Agency (November 2, 2009) (the criteria for coverage for home health skilled nursing services were not met as the evidence fails to show the beneficiaries were likely to have complications or an acute episode that required the observation and assessment by a skilled nurse).
  • In the Case of Rx Home Care, Inc. (November 3, 2009) (the home health services provided to the beneficiary did not meet coverage criteria as filling a mediplanner with medications does not require a skilled nurse and the home health agency is liable for the cost of the services as the advance beneficiary notice was signed by the beneficiary more than a year before the dates of service at issue).
  • In the Case of New Jersey Dept. of Human Services (May 5, 2009) (the evidence of record as a whole supports coverage of home skilled therapy services as the speech-language therapy was aimed at improving the beneficiary's dysphagia in swallowing, rather than merely his speaking abilities).
  • In the Case of Visiting Nursing Association of WNY, Inc. (November 20, 2009) (although an Outcome and Assessment Information Set (OASIS) form is designed to be a comprehensive patient assessment, the OASIS form should not be the exclusive basis for a determination).

Cases involving coverage requirements for inpatient hospital services such as medical documentation requirements.

  • In the Case of Providence Health Center [PDF - 128KB] (June 29, 2012) (The Council adopted the ALJ’s decision that services furnished to the beneficiary are not covered under Medicare Part A, but directed the contractor to provide reimbursement for medically reasonable and necessary and otherwise covered items and services on an outpatient basis under Medicare Part B).
  • In the Case of Indiana University Health Methodist Hospital (May 17, 2012) (The Council concurred with the ALJ that the beneficiary’s condition was not so critical that an acute level of inpatient care was necessary).
  • In the Case of L.B. (Dec. 7, 2011) (The evidence of record demonstrates that the appellant had a qualifying inpatient hospital stay and that the subsequent SNF services provided were medically reasonable and necessary).
  • Illinois Valley Community Hospital (June 16, 2011) (Medicare Part B pays for hospital services and supplies furnished incident to a physician service to outpatients, including drugs that cannot be self administered).
  • In the Case of Montefiore Medical Center (May 10, 2011) (a state legislature may determine state policy for hospitals, but the Social Security Act sets Medicare payment policy).
  • In the Case of O'Connor Hospital (February 1, 2010) (if a Medicare Part A claim is denied, payment may be made for covered hospital services under Medicare Part B).
  • In the Case of St. Francis Hospital (December 29, 2009) (consistent with the Medicare Part A and Part B appeals process under the current applicable statutory and regulatory authorities, either a provider/practitioner or a beneficiary may appeal both the findings on coverage and liability to an ALJ following an inpatient hospital admission denial by a quality improvement organization (QIO))
  • In the Case of Triumph Hospital Detroit (October 27, 2009) (either a beneficiary or a provider may appeal both the findings on coverage and liability to an ALJ following an inpatient hospital admission denial by a quality improvement organization).
  • In the Case of Alta Bates Summit Medical Center (October 26, 2009) (clinical records show the beneficiaries received frequent, direct, and medically necessary physician involvement that was an indicator of the beneficiaries' need for inpatient rehabilitation hospital services).
  • In the Case of Sacred Heart Hospital (November 10, 2009) (while there is no presumption that a treating physician's judgment establishes Medicare coverage, the evidence of record shows that at the time of admission and throughout the hospital stay, the beneficiary required acute inpatient hospital care).
  • In the Case of Kaweah Rehabilitation Hospital (May 13, 2009) (the medical evidence demonstrating the beneficiary's multiple and complex medical problems satisfies the criteria that she receive rehabilitation services in a hospital-level setting as opposed to receiving services at a skilled nursing facility).
  • In the Case of C.A. (November 5, 2009) (the evidence of record meets the criteria for Medicare coverage of a liver transplant for the beneficiary).

Cases involving coverage requirements for inpatient hospital services such as medical documentation requirements.

  • In the Case of Providence Health Center [PDF - 128KB] (June 29, 2012) (The Council adopted the ALJ’s decision that services furnished to the beneficiary are not covered under Medicare Part A, but directed the contractor to provide reimbursement for medically reasonable and necessary and otherwise covered items and services on an outpatient basis under Medicare Part B).
  • In the Case of Indiana University Health Methodist Hospital (May 17, 2012) (The Council concurred with the ALJ that the beneficiary’s condition was not so critical that an acute level of inpatient care was necessary).
  • In the Case of L.B. (Dec. 7, 2011) (The evidence of record demonstrates that the appellant had a qualifying inpatient hospital stay and that the subsequent SNF services provided were medically reasonable and necessary).
  • Illinois Valley Community Hospital (June 16, 2011) (Medicare Part B pays for hospital services and supplies furnished incident to a physician service to outpatients, including drugs that cannot be self administered).
  • In the Case of Montefiore Medical Center (May 10, 2011) (a state legislature may determine state policy for hospitals, but the Social Security Act sets Medicare payment policy).
  • In the Case of O'Connor Hospital (February 1, 2010) (if a Medicare Part A claim is denied, payment may be made for covered hospital services under Medicare Part B).
  • In the Case of St. Francis Hospital (December 29, 2009) (consistent with the Medicare Part A and Part B appeals process under the current applicable statutory and regulatory authorities, either a provider/practitioner or a beneficiary may appeal both the findings on coverage and liability to an ALJ following an inpatient hospital admission denial by a quality improvement organization (QIO))
  • In the Case of Triumph Hospital Detroit (October 27, 2009) (either a beneficiary or a provider may appeal both the findings on coverage and liability to an ALJ following an inpatient hospital admission denial by a quality improvement organization).
  • In the Case of Alta Bates Summit Medical Center (October 26, 2009) (clinical records show the beneficiaries received frequent, direct, and medically necessary physician involvement that was an indicator of the beneficiaries' need for inpatient rehabilitation hospital services).
  • In the Case of Sacred Heart Hospital (November 10, 2009) (while there is no presumption that a treating physician's judgment establishes Medicare coverage, the evidence of record shows that at the time of admission and throughout the hospital stay, the beneficiary required acute inpatient hospital care).
  • In the Case of Kaweah Rehabilitation Hospital (May 13, 2009) (the medical evidence demonstrating the beneficiary's multiple and complex medical problems satisfies the criteria that she receive rehabilitation services in a hospital-level setting as opposed to receiving services at a skilled nursing facility).
  • In the Case of C.A. (November 5, 2009) (the evidence of record meets the criteria for Medicare coverage of a liver transplant for the beneficiary).

Cases involving the calculation of an individual's premium for Medicare Part B based on income level.

  • In the Case of R.F. (October 8, 2009) (gambling winnings are included in the calculation of a modified adjusted gross income but gambling losses are not subtracted).

Cases involving claims for coverage under Medicare Part C, such as all Medicare Part A and Part B items and services must be covered.

  • In the Case of C.L. (January 21, 2016) (the MA plan must cover gender reassignment surgery sought by the enrollee).
  • In the Case of United Healthcare (Feb. 28, 2014) (MA plan not required to provide coverage for enrollee’s ambulance transport)
  • In the Case of D.D.H. (Aug. 22, 2013) (MA plan not required to provide coverage for the iFuse Implant System surgery)
  • In the Case of Network Health Insurance Corp. (April 11, 2012) (a Medicare Advantage Plan must provide enrollees with coverage where the evidence shows the supplies are reasonable and necessary in accordance with Medicare coverage criteria, including applicable NCDs).
  • In the Case of E.T. (March 14, 2012) (finding that the enrollee, at the time of review, met the NCD and LCD criteria for coverage of lap band surgery).
  • In the Case of San Joaquin Valley Rehabilitation Hospital (October 6, 2011) (the medical evidence reveals the required level of medically reasonable and necessary care could have been provided in a less intense setting, rather than in an extended inpatient rehabilitation hospital stay).
  • In the Case of F.M. for the Estate of A.M. (October 6, 2011) (the notice of non-coverage in this case met all requirements for delivery of a valid telephone notice).
  • In the Case of G.S. (October 6, 2011) (the MA plan is not required to authorize surgery which is not available to beneficiaries residing in a plan's service area).
  • In the Case of S.W. (October 6, 2011) (the MA plan covers lenses in accordance with traditional Medicare Part B coverage guidelines, which allow for coverage of standard lenses after cataract surgery, not for coverage of upgraded lenses).
  • In the Case of D.C. (September 23, 2011) (while a Tempur-pedic bed may be beneficial or even medically necessary for the enrollee, the bed is available to the general population, is primarily and customarily used for a non-medical purpose, and does not meet Medicare's definition of covered DME).  
  • In the Case of Kaiser Permanente Senior Advantage (September 15, 2011) (the copayments at issue are the contractual obligations of an enrollee whenever an enrollee receives care under the plan and are not dependent on the degree of the enrollee's satisfaction with, or outcome of, the services rendered).
  • In the Case of B.V. (September 14, 2011) (the enrollee has a legal liability to pay for the non-covered dentures).
  • In the Case of G.S. (September 12, 2011) (the MAO's Evidence of Coverage for dental services is consistent with the coverage criteria under original Medicare and the MA plan is not required to cover the outpatient dental services at issue).
  • In the Case of K.B. (September 9, 2011) (the MA plan is not required to provide coverage for any of the home health aide services provided to the enrollee by a non-licensed provider).
  • In the Case of Kaiser Foundation Health Plan (September 9, 2011) (the record demonstrates that the MA plan's providers could provide the necessary programming services for the enrollee's cochlear implants).
  • In the Case of Evercare by United Healthcare (September 7, 2011) (the ALJ failed to consider the MA plan's policy regarding "out-of-network" providers and suppliers).
  • In the Case of D.K. (September 6, 2011) (the enrollee's obligation to pay the copayment for ambulance services is not eliminated based on the fact that the second transport occurred on the same day as the first transport, was to the same hospital, and needed generally for the same condition).
  • In the Case of P.B.S., D.O., o/b/o P.A.S. (August 26, 2011) (the enrollee has shown that the MA plan's in-network providers are unavailable or inadequate to meet her medical needs and therefore a referral to an out-of-network surgeon is medically reasonable and necessary).
  • In the Case of United Healthcare/Secure Horizons (August 19, 2011) (the application of LCD L26109 to this case allows for only one conclusion, that prostate cancer is not a covered indication for coverage of CyberKnife stereotactic radiotherapy).
  • In the Case of Secure Horizons (April 22, 2011) (placement for court-ordered detention and competency treatment is not equivalent to the temporary unavailability of plan providers under unusual and extraordinary circumstances for purposes of coverage).
  • In the Case of J.B. (December 14, 2010) (The MA plan was not required to pay for out-of-network services provided to enrollee when enrollee failed to establish that an urgent situation existed particularly where the MA plan offered two treatment programs which enrollee refused, the enrollee was not outside of the MA plan's service area when the need for the care arose, and the enrollee did not suffer from an unforeseen illness or injury).
  • In the case of Kaiser Foundation Health Plan, Inc. (July 13, 2010) (the MAO's denial of an out-of-plan referral for surgery and subsequent administrative determination that it could cover the removal of the an implant if an in-plan doctor confirms the rupture of that specific implant despite the recommendations of two doctors that both implants be removed, was a denial of basic covered benefits in accordance with the EOC's reconstructive surgery coverage provisions).
  • In the case of A.M.R. (April 19, 2010) (because the enrollee provided evidence that the network providers were unavailable or inadequate to meet her medical needs, a referral by her primary care physician to an out-of-network provider is medically reasonable and necessary and covered by the MA plan).
  • In the case of Care Improvement Plus (March 15, 2010) (brief inpatient care of MA enrollee was medically necessary after attending physician considered the enrollee's medical status and foreseeable adverse consequences in light of the enrollee's pre-existing cardiac condition).
  • In the case of United HealthCare d/b/a Evercare (February 16, 2010) (on remand, the ALJ properly considered the IRE doctor consultant's opinion, whose identity remained anonymous, and the written interrogatories and interrogatory answers provided by an independent medical expert in reaching his decision).
  • In the case of Desert Valley Hospital (February 16, 2010) (the medical opinion by a treating physician that an enrollee is stabilized for transfer or discharge triggers an emergency provider's obligation to notify the MAO, reasonably within an hour of the point at which the enrollee is stabilized, as well as the MAO's financial responsibility for the post-stabilization care of the enrollee).
  • In the Case of PacifiCare (November 2, 2009) (a maintenance exercise program is an unskilled service that does not require the special skills of a licensed therapist and the Medicare Advantage plan is not required to cover the skilled nursing facility services).
  • In the Case of G.L. (September 21, 2009) (the facts of the case do not warrant an exception and the Medicare Advantage plan is not required to provide coverage for services provided by a skilled nursing facility that is not a plan provider).
  • In the Case of D.C. (October 27, 2009) (the Medicare Advantage plan is not required to provide coverage of, or reimbursement for, air ambulance services furnished to the enrollee from Mexico to the United States after he suffered a fall while on vacation).
  • In the Case of R.C. (September 28, 2009) (a Medicare Advantage plan must comply with local coverage determinations but policy articles are not binding).
  • In the Case of Kaiser Foundation Health Plan Hawaii* (August 15, 2008) (the Medicare Advantage plan is not required to cover the enrollee's out-of-plan liver resection surgery and associated post-surgery hospitalization expenses as the enrollee did not qualify for urgently needed care and the plan did not make their providers unavailable, inaccessible or inadequate to meet her needs).
  • In the Case of Blue Cross of Idaho (November 20, 2009) (the Medicare Advantage plan is required to reimburse the skilled nursing facility for the covered services instead of directly paying the enrollee's estate).
  • In the Case of Connecticut Dept. of Social Services* (November 16, 2009) (a Medicare Advantage plan must provide enrollees with all items and services covered by Medicare Part A and Part B available to beneficiaries residing in the plan's service area and the plan is required to cover skilled nursing services as defined by regulation).
  • In the Case of M.D. (December 4, 2009) (a Medicare Advantage plan must provide necessary specialty care or arrange for specialty care outside the plan provider network when network providers are unavailable or inadequate to meet the enrollee's medical needs).

Cases involving repayment of conditional payments made by Medicare on behalf of a beneficiary.

  • In the case of T.P., surviving spouse, & J.P., C.P., & A.B., next of kin (August 16, 2016) (The beneficiary's estate could not avoid Medicare recovery by classifying the settlement, after the fact, as being entirely under the Illinois Wrongful Death Act when, at the time the settlement amount was agreed to, claims for both wrongful death and medical malpractice were pending, but Medicare was only entitled to recover from the portion of the settlement attributable to the medical malpractice claims.) Affirmed at Paraskevas v. Price, Docket No. 16 CV 9696 (N.D. Ill. Nov. 27, 2017).
  • In the Case of E.M.P. (June 28, 2011) (the Council orders three charges removed from the Medicare lien assessed against the appellant, noting that the ICD identifies a condition while the HCPCS identifies a treatment for that condition).
  • In the Case of F.G. (October 20, 2010) (A settling party must consider Medicare's right of recovery when negotiating a settlement amount).
  • In the Case of M.B.C. (March 19, 2010) (the beneficiary is not liable for Medicare payments for treatment associated with a lower back injury under the Medicare Secondary Payer Act as the evidence of record shows these treatments are unrelated to the cervical spine injuries that resulted in a workers' compensation settlement).
  • In the Case of W.G. (November 10, 2009) (the beneficiary is required to repay the conditional payments made on her behalf for medical treatment following an automobile accident as all medical expenses are presumptively included in a settlement amount).
  • In the Case of A.H. (November 6, 2009) (Medicare is entitled to recover from settlement proceeds without regard to how the settlement agreement stipulates disbursement should be made, even if the parties agreed that a portion of the settlement proceeds are unrelated to the accident or injury).

Cases involving issues unique to overpayments made by Medicare, to include the use of statistical sampling.

  • In the Case of Sans Bois Health Services, Inc. [PDF – 146KB] (October 30, 2014) (extrapolated overpayment based on valid sampling methodology).
  • In the Case of Anthony Pagliarulo, M.D. [PDF – 82KB] (Sept. 26, 2014) (The Council reversed the ALJ’s invalidation of sampling methodology underlying the extrapolated overpayment).
  • In the Case of Discount Diabetic [PDF – 59KB] (June 29, 2012) (The Council determined that pursuant to section 1870(b) of the Act, the appellant is waived from recovery of the overpayment).
  • In the Case of Robert D. Lesser, M.D. & Associates [PDF - 102KB] (Dec. 7, 2011) (The ALJ erred by invalidating the statistical sample in this case and by waiving the appellant’s liability for all overpayments during the applicable time period).
  • In the Case of Steven Kalter, M.D. (August 11, 2011) (a contractor only needs to account for underpayments that have been uncovered as the result of an audit when calculating an overpayment, it need not actively pursue underpayments).
  • In the Case of Meridian Laboratory Corporation (June 24, 2011) (the appellant is obligated to provide supporting documentation to establish the medical necessity of the sampled claims).
  • In the Case of John Sanders, M.D. (May 12, 2011) (the Council determines that the sampling was sufficiently flawed to preclude calculation of an overpayment by extrapolation and the appellant is financially liable only for the overpayments on the individual claims in the sample).
  • In the Case of Michael King, M.D. and Kinston Medical Specialists, P.A. (May 10, 2011) (the Council need not find that CMS or its contractor undertook statistical sampling and extrapolation based on the most precise methodology that might be devised in order to uphold an overpayment extrapolation but instead the test is whether the methodology is statistically valid).
  • In the Case of Charles Stockwell, O.D. (PDF - 118K)   (February 14, 2011) (Prior to applying the waiver provisions of sections 1879 and 1870,  the ALJ should have first determined whether services provided to the beneficiaries in each case met the coverage provisions of the Act).
  • In the Case of Global Home Care, Inc. (PDF - 77K)   (January 11, 2011) (When the record does not contain complete documentation to recreate the sampling frame, a provider does not have the information and data necessary to mount a due process challenge to the statistical validity of the sample).
  • In the Case of The Endocrine Clinic, P.C. (PDF - 158K)   (November 10, 2010) (While the appellant contends that the Medicare contractor erred in recalculating Medicare's overpayment following the ALJ's decision, the regulations contemplate that an ALJ's decision is not final for the purposes of determining the amount of payment due).
  • In the Case of Excel Diagnostics, Ltd. (PDF - 141K)   (October 14, 2010) (Medicare payment is appropriate for diagnostic doses of Indium-111 administered to beneficiaries during a clinical trial but payment is denied for additional therapeutic doses).
  • In the Case of Podiatric Medical Associates (June 22, 2010) (appellant was deprived of its ability to review the extrapolation in question when PSC failed to provide pertinent audit-related information).
  • In the Case of Home Care 4 U, Inc. (May 25, 2010) (overpayment cannot be sustained as a matter of due process when the PSC has failed to provide evidence in the record to support its finding that the treating physician did not sign the plans of care at issue).
  • In the Case of American Health Network of Indiana, LLC, and Adam D. Perler, D.P.M. (February 25, 2010) (the ALJ erred in addressing the issues of coverage and liability when the Council had addressed these issues prior to remanding the case back to the ALJ to address the sole issue of whether the appellant was "without fault" under the provisions of section 1870(b) of the Act).
  • In the Case of Maxxim Care, EMS (February 25, 2010) (CMS or its contractor must use a statistically valid methodology for sampling and extrapolation, not necessarily the most precise methodology that might be devised).
  • In the Case of Idaho Falls Chiropractic Clinic, P.L.L.C. (February 22, 2010) (in a probe review, contractors collect overpayments only on claims that are actually reviewed and may not extrapolate the overpayment to a universe of claims pursuant to the MPIM).
  • In the Case of KGV Easy Leasing Corporation (February 22, 2010) (beneficiary information submitted that does not indicate that the referring physician was the treating physician, that the treating physician used results from diagnostic tests in managing the patient, or present a complete clinical picture of the medical conditions that presumptively warranted the testing fails to demonstrate that the claims were medically reasonable and necessary for the purposes of Medicare coverage).
  • In the Case of Mid South Psychiatric Associates (December 23, 2009) (the fact that the appellant filed individual requests for ALJ hearing, rather than discussing the basis for re-adjudicating sampled claims in one submission, does not require that the appellant seek aggregation of those claims in order to exercise appeal rights of an extrapolated overpayment).
  • In the Case of Lakeside Foot Clinic (October 15, 2009) (in a case arising from an overpayment based on statistical sampling, an appellant must be given an opportunity to challenge both the findings on the individual services reviewed in the sample and the sampling methodology and extrapolation).
  • In the Case of Transyd Enterprises, LLC (September 15, 2009) (the burden is on the appellant to prove the statistical sampling methodology was invalid and not on the contractor to establish that it chose the most precise methodology).
  • In the Case of Whidbey General Hospital* (December 3, 2007) (the appellant had sufficient notice at the time the provider billed and received payment for the supplied drugs to identify the overpayments received and the recovery of the overpayment is not waived under section 1870(b) of the Social Security Act).
  • In the Case of Quality Home Health Services, Inc. (September 14, 2009) (the appellant does not challenge the validity of the statistical sample or the extrapolation methodology but instead focuses the appellate arguments on the individual claims for home health services).
  • In the Case of Lance E. Daniel, O.D. (December 3, 2009) (if, as in this case, some of the individual sample claims were wrongly denied, the overpayment is re-extrapolated based on the remaining denied claims in the sample).

Cases involving an enrollee's claim for coverage of a prescription drug under the Medicare prescription drug program.

  • In the Case of L.P. (May 6, 2014) (Part D plan not required to cover or pay for diclofenac and liothyronine)
  • In the Case of C.D. (Sept. 30, 2013) (The Council reversed the ALJ’s decision, finding that the plan was not required to cover or pay for Theraproxen for the enrollee)
  • In the Case of J.R. [PDF – 99KB] (September 20, 2013) (The Council reversed the ALJ, finding there was no authority to grant a tiering exception for the enrollee’s modafinil under the facts of this case).
  • In the Case of J.S. [PDF – 60KB] (July 5, 2012) (The enrollee did not establish that he qualifies for a formulary exception because there is no evidence that each of the formulary drugs is either ineffective or contraindicated).
  • In the Case of K.M. (April 10, 2012) (contrary to the ALJ’s finding, and based on the medical records and supporting statements from the beneficiary’s treating physician, the drug prescribed was not for an off-label use).
  • In the Case of R.S. (September 8, 2011) (the Council is bound to follow the Secretary’s implementing regulations and the enrollee’s use of the prescribed drug is not for a “medically accepted indication”).
  • In the Case of E.D. (PDF - 60K)   (March 4, 2011) (Under the terms of the Evidence of Coverage, the Part D Plan is responsible for paying at least a portion of the cost of the drug Thalomid dispensed to the enrollee during the initial coverage period and the catastrophic coverage period).
  • In the Case of S.A.B. (December 11, 2009) (because the drug prescribed for the enrollee's autoimmune conditions is for an off-label use and is not supported in a compendia for treatment of any of the conditions with which the enrollee is diagnosed, it is not a covered Medicare Part D drug).
  • In the Case of V.B.M. (October 8, 2009) (the prescribed drug qualifies for a exception and is eligible for Part D coverage as compendia recognized as an authoritative source for determining coverage status of prescription drugs includes the prescribed drug as a grandfathered drug that was marketed for the prescribed use prior to the enactment of the Federal Food, Drug and Cosmetic Act of 1938 and therefore has technically never been "approved" by the Food and Drug Administration).

Cases involving coverage requirements for physician services such as medical documentation requirements.

  • In the Case of Marc E. Umlas, M.D. [PDF – 27KB] (May 17, 2013) (Medicare payment for a series of knee x-rays)
  • In the Case of Cancer Care Associates [PDF – 112KB] (April 19, 2013) (Although the applicable LCD has since been revised to include language adding the diagnosis code for pancreatic cancer to the list of diagnosis codes that support medical necessity, the Council cannot apply LCDs retrospectively. Therefore, there is no coverage available for the levoleucovorin calcium injections at issue).
  • In the Case of Delphi Hospitalist Services [PDF – 115KB] (December 19, 2012) (ALJ lacked authority to review effective date of physician’s enrollment in Medicare program).
  • In the Case of Art Ankle & Foot Care Specialist [PDF – 86KB] (June 28, 2012) (On remand, the Council instructed the ALJ to make a determination based on the record evidence as it pertains to each beneficiary and to issue a new decision which explains the basis for the decision consistent with applicable regulations and other relevant coverage authorities). 
  • In the Case of Sunrise Family Foot Center [PDF – 83KB] (June 18, 2012) (The Council affirmed the ALJ’s ultimate conclusion that Medicare will not cover the services at issue, but supplemented the ALJ’s decision to set forth the applicable Medicare coverage criteria).
  • In the Case of Med Health Services [PDF – 70KB] (June 14, 2012) (The Council found that the CPT codes 93320 and 93325 were component codes of 93306 during the dates of service at issue and that they are not separately reimbursable).
  • In the Case of Radiation Oncology Healthcare, P.A. [PDF – 86KB] (June 11, 2012) (Finding that the NCCI edits in effect for the dates of service at issue indicate that the use of a modifier is not appropriate to override the payment restriction).
  • In the Case of K.E.D. (June 22, 2012) (Medicare did not cover the pap smear and related service because the appellant did not satisfy the criteria set forth in the applicable statutory provisions and NCD).
  • In the Case of Harlan Appalachian Regional Hospital (June 13, 2012) (The Council determined that the appellant did not furnish sufficient documentation to establish that the service at issue was medically reasonable and necessary).
  • In the Case of Comprehab Wellness Group (May 17, 2012) (The supplier did not meet its burden based on binding regulations and interpretative manual sections pertinent to CORF services).
  • In the Case of Caris MPI, Inc. (April 24, 2012) (finding that the ALJ erred when it failed to: 1) review the Qualified Independent Contractor’s dismissals of the requests for reconsideration; 2) afford substantial deference to the applicable LCD or provide reasons for not doing so; and 3) make a determination as to whether the services not specified in the LCD’s coverage requirements are reasonable and necessary, and not experimental and investigational, as set forth in the MPIM).
  • In the Case of Steven B. Cagen, M.D., P.C. (April 12, 2012) (applicable authorities provide that Medicare Part B payment may not be made for the technical component of the services in question when the services are furnished to hospital inpatients).
  • In the Case of Junichiro Sageshima, M.D.(June 27, 2011) (the use of an inappropriate modifier resulted in more than a minor clerical error and therefore the claim is subject to the appeals process).
  • In the Case of North Alabama Neurological, P.A. (November 22, 2010) (The ALJ erred by focusing on the issue of the amount of payment  instead of the issue of whether the surgical procedure on the date of service was reasonable and necessary).
  • In the Case of Health Spring, Inc.  (November 16, 2010) (The MOA is not bound to cover the non-emergency oncology and laboratory services provided by an out-of-network physician where there was no evidence that the enrollee sought a referral or authorization from the MOA to see an out-of-network physician).
  • In the Case of Robert E. Rothfield, M.D. (December 16, 2009) (the record indicates the beneficiary's breast implant surgery was not cosmetic in nature but was a medically required revision of a previous reconstruction after a bilateral mastectomy due to breast cancer).
  • In the Case of Rocky Mountain Anaplastology, Inc. (December 8, 2009) (the billed facial template utilized by a surgeon during a surgical implant procedure does not fall within the definitions of services or supplies "incident to a physician's service" or the definition of a prosthetic device).
  • In the Case of Starosta Medical PC (September 23, 2009) (an appellant has the burden to provide sufficient documentation, evidence and testimony that indicates the services provided are covered by Medicare).
  • In the Case of Advanced Diabetes Treatment Centers* (August 26, 2009) (the billed services do not qualify for Medicare coverage as the services do not fall within the definition of "monitoring" a subject of a clinical trail for Medicare coverage of routine costs because the tests were a critical component of the clinical trials for Pulsatile Intravenous Insulin Therapy).

Case involving overpayment appeals that arose under the RAC program.

  • In the Case of Memorial Long Beach (July 23, 2008) (a contractor's decision on whether to reopen and whether the contractor met the good cause standards for reopening are not subject to administrative review by ALJs or the Council but lie within CMS's evaluation and monitoring of the contractor's performance).
  • In the Case of Holy Cross Hospital (May 13, 2009) (Section 1870(b) of the Social Security Act creates a rebuttable presumption of no fault on a provider's part where an overpayment determination is made subsequent to the third year in which payment notice was issued; section 1870(c) applies to a wavier of overpayments made to a beneficiary, not a provider).
  • In the Case of St. Francis Memorial Hospital (May 7, 2009)  (only the year of the payment and the year it was found to be an overpayment are considered for calculating the three-year calendar period, not the day and month).
  • In the Case of Valley Presbyterian Hospital (July 29, 2009) (while the RAC's decision to reopen the claim at issue is not subject to review by the ALJ and the Council, the assessed overpayment is not valid as the evidence of record supports payment for the provided inpatient rehabilitation facility services).
  • In the Case of Baptist Health Care (June 26, 2009) (limitation of liability under section 1879 of the Social Security Act is not appropriate as the provider had knowledge that Medicare would not pay for the services based on the fact CMS had issued relevant manuals, bulletins, and written guidelines; performance of post payment review itself did not constitute knowledge of noncoverage of services provided and billed for prior to the assessment of the overpayment).

Cases involving coverage requirements for skilled nursing facility services such as notification and medical documentation requirements.

  • In the Case of L.R. (Feb. 21, 2014) (denying Medicare coverage for SNF services at issue, appellant’s reliance on the Jimmo v. Sebelius litigation is unavailing)
  • In the Case of State of Connecticut (allowing Medicare coverage for SNF services at issue)
  • In the Case of Commissioner, Connecticut Department of Social Services [PDF – 128KB] (August 23, 2013) (The Council reversed the ALJ and found that Medicare will cover the home health services at issue).
  • In the Case of Restore Management Company (Mar. 20, 2013) (the Council modified the ALJ’s decision and made specific determinations regarding the appropriate RUG codes at issue).
  • In the Case of Brittany Farms Health Center [PDF – 175KB] (December 28, 2012) (The Council reversed the ALJ’s decision and found the provider, not the beneficiary, liable for the non-covered services).
  • In the Case of Meadow View Manor [PDF – 126KB] (June 20, 2012) (The record demonstrates that the therapy services rendered to the beneficiary were not medically reasonable and necessary).
  • In the Case of Village at Cook Springs [PDF - 68KB] (June 14, 2012) (The Council modified the ALJ’s decision to clarify that since both the rehabilitative therapy and the nursing services provided to the beneficiaries failed to satisfy the applicable Medicare coverage criteria, no Medicare reimbursement is available for the appellant’s claims associated with those beneficiaries).
  • In the Case of J.A.C.(June 13, 2012) (The evidence does not support the conclusion that skilled nursing services were required or received for the enrollee’s condition).
  • In the Case of Estate of B.A., by ***, personal representative. (Dec. 5, 2011) (The Council found that the provider, and not the beneficiary, was liable where the provider failed to notify the beneficiary that Medicare would not cover the services furnished).
  • In the Case of Commissioner, Connecticut Department of Social Services (November 21, 2011) (an Expedited Determination generic notice by itself provides insufficient notice in a situation where all Medicare-covered services are ending but the provider intends to deliver non-covered care).
  • In the Case of Apple Rehab, Inc. (November 17, 2011) (the evidence shows beneficiary became sufficiently dehydrated to require intravenous fluids which is per se skilled nursing service under Medicare regulations).
  • In the Case of Ottawa County Riverview Nursing Home (September 7, 2011) (evidence showing the beneficiary went from requiring minimal assistance with activities of daily living to requiring the assistance from two persons for similar functions supports the intervention of skilled rehabilitation services).
  • In the Case of A.L. (PDF - 29K)   (January 21, 2011) (The beneficiary died after filing a request for hearing before an ALJ. The appellant has not demonstrated that she is authorized to act on behalf of a proper party, or otherwise has any interest as a substitute party).
  • In the Case of Commissioner, State of New Jersey Dept. of Human Services (PDF - 23K)   (Whether skilled nursing services are, or are not, medically reasonable and necessary, is a determination that must be made solely on the beneficiary's unique condition and individual needs, without regard to whether the illness or injury is acute, chronic, terminal or expect to last a long time).
  • In the Case of Twin Maples Health Care Facility (PDF - 111K)   (December 10, 2010) (Although the physical therapy the beneficiary received at the appellant's SNF was both skilled and necessary its delivery, alone, does not qualify the SNF for Medicare coverage of the beneficiary's stay. Medicare coverage is appropriate for the dates of service the beneficiary received skilled nursing services she required and received for her mental health problems).
  • In the Case of Roman Eagle Memorial Home, Inc. (June 10, 2010) (the beneficiary is not liable for two stays at the SNF in a noncertified bed as the record reveals the SNF's notice of Medicare non-coverage to beneficiary's minor daughter during the first stay was defective and the SNF failed to demonstrate any attempt to obtain a valid consent from the beneficiary during the second stay).
  • In the Case of Connecticut Dept. of Social Services (February 24, 2010) (the beneficiary is liable for the non-covered services as the record demonstrates the beneficiary received non-skilled services at the SNF during dates at issue and the SNF gave proper notice of Medicare non-coverage).
  • In the Case of Connecticut Dept. of Social Services (January 11, 2008) (the record shows the beneficiary did not possess the requisite capacity to qualify as a capable recipient when he signed the notice of non-coverage).
  • In the Case of Connecticut Dept. of Social Services (July 28, 2009) (the medical evidence records the beneficiary's unstable condition and her need for skilled care and shows the management and evaluations of the beneficiary's care plan constituted skilled care).
  • In the Case of Elmhurst Care Center (September 29, 2009) (certification of the necessity for skilled services on an inpatient basis in a skilled nursing facility may be contained in progress notes, orders, or other documents that have been signed by the physician, not just in a separate form).
  • In the Case of Connecticut Dept. of Social Services (September 14, 2009) (the evidence of record shows the beneficiary received intramuscular injections, which constitute skilled nursing services).
  • In the Case of Elmhurst Care Center (October 16, 2009) (documentation of the beneficiary's hospital medication history is required to show which medications the beneficiary had received and to show the medication history was considered for her medical care at the skilled nursing facility).
  • In the Case of Elmwood Health Center (October 30, 2009) (the issue of physician certification is not an element of coverage but is a condition for payment).
  • In the Case of Crystal Lake Healthcare and Rehabilitation Center (February 15, 2007) (Medicare Part B does not cover separate Part B payment to a skilled nursing facility of routine blood glucose testing under a standing order unless the physician is informed of the results of each test promptly and prior to the performance of the next test and the results are used to manage the beneficiary's treatment).
  • In the Case of Berkshire Healthcare* (February 19, 2008) (Medicare coverage is denied as the record fails to show that the physicians were promptly notified of the results of each blood glucose test before the next test was given).

Cases involving coverage determinations for inpatient and outpatient therapy services.

  • In the Case of Iron Run Orthopedics [PDF – 300KB] (September 27, 2013) (the Council adopted the ALJ’s decision and found that Medicare would not cover the therapy services at issue).

Cases involving coverage requirements for issues such as chiropractic services and surgical dressings.

  • In the Case of E.K. [PDF – 97KB] (December 12, 2012) (Both laboratory tests were covered under CMS policy).
  • In the Case of Michael Schill, DC. [PDF – 112KB] (June 21, 2012) (The record did not demonstrate that the subluxations at issue were chronic in nature and that there was a reasonable expectation of functional improvement in the beneficiary’s condition).
  • In the Case of Amigo Home Health Hospice Agency (April 24, 2012) (contrary to the ALJ’s findings, none of the blood glucose tests were covered under Part B because in order for glucose monitoring service to qualify for separate payment the service must be performed in accordance with laboratory coverage criteria, which includes prompt notification of each and every test result).

  • In the Case of Shawn Lee, D.C. (August 29, 2011) (the SOAP/plans of care submitted by the appellant do not, alone, consititute proper documentation of chiropractic manipulation).

  • In the Case of Gordian Medical, Inc., d/b/a American Medical Technologies*  (August 8, 2011) (neither the ALJ or the Council has the authority to review HCPCS definitions).
  • MP Totalcare/CCS Medical (June 22, 2011) (the evidence produced by the appellant must contain sufficient documentation of the beneficiary's medical condition to substantiate the necessity for the type and quanitity of the items ordered).
  • In the Case of R.J. (December 31, 2010) (The beneficiary's blood glucose testing logs, with the additional documentation of record, satisfies the coverage criteria set forth in the applicable LCD).
  • In the Case of Dynamic Rehabilitation Services (October 21, 2010) (LCD L5017 precludes a supplier or an individual with a financial relationship with the supplier from completing the medical necessity forms).
  • In the Case of Jacksonville Hearing & Balance Institute (August 2, 2010) (the applicable LCD does not provide billing or payment guidance and the record does not support the use of the -59 modifier to bypass the MUE (Medically Unlikely Edit) in effect during the period of service at issue).
  • In the Case of Ridgefield Surgical Center (February 18, 2010) (an ambulatory surgical center is not entitled to Medicare payment of a facility fee for a procedure billed used an unlisted procedure code).
  • In the Case of CourierMed, Inc. (November 24, 2009) (the supplied dressings are covered under the ESRD composite rate and therefore are not separately billable).
  • In the Case of LaPorte Chiropractic (October 30, 2009) (the submitted evidence lacks the specific information about the onset and duration of the beneficiary's symptoms or past health history and is insufficient to support Medicare coverage for chiropractic services).
  • In the Case of Kohll's Pharmacy & Homecare, Inc. (September 30, 2009) (the surgical dressings are not covered by Medicare as the medical evidence shows the dressings were not used for a surgical or debrided wound).
  • In the Case of Klaes Chiropractic Clinic, Inc. (November 18, 2009) (chiropractic services must be furnished within a reasonable period of time to qualify for Medicare coverage).
  • In the Case of Texas Oncology (October 21, 2009) (the ALJ erred in basing his decision solely on unidentified provisions of a local coverage determination without considering whether there is supportive clinical evidence for the off-label use of a prescribed drug).
 
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