LymphActivist's Site
Dedicated to Lymphedema Patients and the Therapists Who Treat Them
LymphActivist's Site
Dedicated to Lymphedema Patients and the Therapists Who Treat Them
LymphActivist's Site
Dedicated to Lymphedema Patients and the Therapists Who Treat Them
Porter Ranch, CA
June 28, 2019
Demetrios L. Kouzoukas, Principal Deputy Administrator for Medicare
Department of Health and Human Services
Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244
Demetrios.Kouzoukas@cms.hhs.gov
The Honorable Constance B. Tobias, Chair
Department of Health and Human Services
Departmental Appeals Board
330 Independence Avenue, SW
Washington DC 20201
Email: DABHotline@hhs.gov
Judge Nancy Griswold, Chief Administrative Law Judge
Office of Medicare Hearings and Appeals Headquarters
2550 S. Clark Street, Suite 2001
Arlington, VA 22202
Email: Medicare.Appeals@hhs.gov
Joanne M. Chiedi, Acting Inspector General
Office of the Inspector General
330 Independence Avenue, S.W.
Washington, DC 20201
Ruth.Davis@OIG.hhs.gov
SUBJECT: Suggestion for Improved Beneficiaries’ Health While Preserving Medicare Resources
This letter is being sent to heads of Department of Health and Human Services (HHS) offices to alert you as to what I believe to be a lack of implementation of Medicare procedures leading to a waste of resources, and which CMS steadfastly refuses to address in a professional manner.
In this day of evidence-based medicine and uncontained growth of medical costs, I think that CMS would want to enforce the terms of their contracts with Medicare Administrative Contractors. This would also resolve a coverage issue of long standing which deprives (with no valid basis in law or medicine) as many as 2 million Medicare beneficiaries with diagnosed lymphedema of the primary modality of their medical treatment.
Attempts to show CMS how the compression bandages and garments, which are the mainstay of lymphedema treatment, meet the coverage criteria for prosthetic device benefits have failed. In this patient advocate’s experience with over 100 appeals, the majority of the Administrative Law Judges ruled in the beneficiary’s favor and ordered payment for these denied items. Their decisions followed relevant statutes and were based on the evidence in the case record, whereas CMS’s objections were based on inappropriate analogies and did not address available medical and clinical evidence in the case record. Formal requests have been made to open this issue to public and medical comment in a National Coverage Analysis leading to a National Coverage Determination, but CMS has refused to comply with their own policies.
The latest attempt on CMS’ part to transfer cost from the Medicare trust fund to the Medicare beneficiary is a blatant attack on the capability of OMHA to make independent decisions. An administrative contractor, the AdQIC, questions the legal decisions of ALJs when the ALJ’s decision is unfavorable to CMS.
It would be more effective and less costly to have the DME MACs make determinations of benefit categories of claims per their Supplier Manuals instead of making denials on the basis that “no beneficiary category exists”. The DME MACs may not have the medical and/or legal capability of making this determination. CMS should open a National Coverage Analysis and consider the inputs of medical and legal experts to debate the issue of whether compression bandages and garments already meet the coverage criteria for prosthetic device benefits per the definition in the Medicare Benefit Policy Manual, CMS Pub. 100-02, Chapter 15, §120.
The irony of the situation is that the treatment of lymphedema in its early stages is being shown to: prevent or retard progression to harder-to-treat stages; prevent recurrent infections requiring hospitalization; and avoid or delay beneficiary disability. Recent 10 years of experience in Virginia, where the provision of compression items to treat lymphedema has been mandatory since 2004, shows a reduction in doctor visits and hospitalizations due to lymphedema. The claim costs of treating lymphedema has been shown to be between $1.59 and $3.24 per patient per year (less than 0.1% of total claim costs). www.lymphactivist.org/potential_savings.php and www.lymphactivist.org/cost_of_mandate-10years.pdf
In the interest of a more efficient Medicare I urge you to do whatever is within your authority to encourage CMS to follow Medicare statutes and their own written policies. This could provide a solution that not only improves the quality of care for Medicare beneficiaries, likely to result in avoidance or reduction of resources required to treat lymphedema-related cellulitis and disability.
Thank you for your attention.
(signed)
Robert Weiss, MS, Lymphedema Patient Advocate
Email: LymphActivist@aol.com Web Site: http://www.lymphactivist.org
References:
• How Are Compression Bandages, Garments, Devices and Supplies Coverable under the Social Security Act? Robert Weiss http://www.lymphactivist.org/prosthetic_devices-insert.pdf
• A Formal Request for a National Coverage Determination Coverage of Lymphedema Compression Treatment Items as Prosthetic Device Benefits http://www.lymphactivist.org/ncd_request.php