GOVERNMENTMedicare denials can be appealed: CMS acts following lawsuitThe right to appeal is seen as essential to ensuring that Medicare allows physicians to provide the best treatments, and get reimbursed.By Markian Hawryluk, amednews staff. Sept. 2, 2002. Washington -- Seniors Lois Jalbert, Robert Kennell and Barbara McAuliffe decided to take on Medicare to fight for coverage of a treatment they believe is the only reason they still have vision. Their battle may have sparked government action that could have wide implications for physicians' freedom to recommend the best treatment and get paid for it. The three patients have occult age-related macular degeneration and have been effectively treated with ocular photodynamic therapy using Visudyne. But Medicare won't pick up the $1,800 tab per treatment. What's worse is that Medicare would not even let them appeal that decision. So the three joined the American Assn. of People with Disabilities, the American Council for the Blind, and the Gray Panthers in a lawsuit filed in early August and seeking an injunction against the government's decision not to pay for Visudyne (verteporfin for injection). The injunction would last until the patients' appeal could be heard. Although Congress approved legislation requiring an appeals process for national Medicare coverage decisions in 2000, the Centers for Medicare & Medicaid Services missed the October 2001 deadline for establishing it. But just weeks after the Visudyne suit was filed, CMS finally proposed regulations that would govern such appeals. The regulations, published in the Aug. 22 Federal Register, will allow national coverage decisions, such as the Visudyne ruling, to be challenged. The right to appeal is critical for seniors and their doctors, physicians said. For treatments that benefit primarily an older population, lack of Medicare coverage virtually eliminates access to that treatment and impacts physicians' ability to practice.
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