Download as Microsoft document

[Your Address]

HHS OMHA Central Operations
200 Public Square, Suite 1260
Cleveland, OH 44114-2316
Attn: Beneficiary Mail Stop

QIC Appeal Number [Number from QIC Reconsideration Letter]

Beneficiary: [Name], HICN [SSN]
Items in Dispute: [Description, Number, Cost]
Date of Service: [Date items were received]
Supplier: [Name of Medicare-enrolled Supplier]
Claim Number: [From quarterly Medicare Summary Notice]
Denial on Medicare Summary Notice: [Date of MSN]
Redetermination by [Name of DME MAC]: [Date on Redetermination Letter]
Reconsideration by C2C Solutions QIC DME: [Date on Reconsideration Letter]

References (In the case record)

  1. Appointment of Representative Form CMS-1696 (07/05) dated [Date Representative signed].
  2. Medicare Reconsideration Decision Letter, C2C Solutions, [Date on Reconsideration Letter;
  3. How Are Compression Bandages, Garments, Devices and Supplies Coverable under the Social Security Act [Available at], Revision [ ] dated [Date of Revision].

This request for a hearing by an Administrative Law Judge is being submitted by [Name of Appellant] to consider the Medicare Reconsideration Decision (Reference 2) by the Medicare QIC DME, C2C Solutions.

We dispute the determination in the Medicare Reconsideration Decision (Reference 2) on many counts. A detailed rationale for disputing the original determination is given in a 46-page legal and medical evidence document (Reference 3) to be considered as part of this Request. Specific issues are as follows:

  1. Omission of Relevant Reference. On page 2 of Reference 2, in the Explanation of the Decision, the DME QIC omits the one CMS IOM manual that is most relevant to this issue, i.e. the Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 120 Prosthetic Devices. This manual defines and distinguishes, in Chapter 15, Covered Medical and Other Health Services.

    The central issue in this appeal concerns whether the compression stockings when medically used for compression therapy in the treatment of lymphedema, ICD-9 code 457, meet the Medicare coverage criteria for items which fall into the covered benefit category of "prosthetic devices".

  2. Neglecting to determine Benefit Category of Disputed Items. Before applying any Local Coverage Determination (LCD) to see if an item meets the medical necessity criteria for a specific benefit category, the DME MAC is required to determine which benefit category may apply, and then select the appropriate LCD to apply. This was never done. It was immediately assumed that these lymphedema compression garments were "surgical dressing" benefits since they resemble certain secondary surgical dressings used in the treatment of venous ulcers, and a surgical dressing LCD was used to deny them. But, as pointed out in detail in Reference 3, the medical use of compression garments in the treatment of lymphedema is different from the medical use of surgical dressings, and they fall into a different benefit category. Note that benefit categories in §1861(s) of the Social Security Act are defined by their function and not their form.

    It is also logically true that an item can fail to meet the coverage requirements of one benefit category, but still meet the criteria for a different benefit category. This is true in the instant case where a compression garment used in the compression therapy of lymphedema fails to fall into the surgical dressing benefit category because there is no debrideable wound, but meets the different criteria for prosthetic devices which require that they replace a part of the function of a permanently inoperative or malfunctioning internal organ.

  3. Use of HCPCS Code to determine Coverability. Medicare has assigned an HCPCS Code of [Axxxx] to the compression garment in dispute, and then denies their coverage based on this assigned number. The HCPCS Code is an administrative tool to provide a description for a medical item. The HCPCS Code does not confer or deny coverage. This is made clear in the HCPCS Level II Coding explanation:

    "HCPCS is a system for identifying items and services. It is not a methodology or system for making coverage or payment determinations, and the existence of a code does not, of itself, determine coverage or non-coverage for an item or service. ... The coding system is not a methodology for making coverage or payment determinations. Each payer makes determinations on coverage and payment outside this coding process."

    The payer (DME MAC) has failed to do this.
  4. Application of Inappropriate Local Coverage Determination. On page [ ] of Reference 2, the DME QIC selects the Local Coverage Determination (LCD) for Surgical Dressings (L27222) and its related Local Policy Article for Surgical Dressings (A47232) to test for meeting the medical necessity criteria for the lymphedema compression garments at issue. The coverage exclusion in this LCD only applies to coverability of graduated compression stockings "because they do not meet the definition of a surgical dressing". The DME MAC then extends the surgical dressing exclusion to the general exclusion "noncovered under Medicare policy".

    This Article on the medical necessity criteria for surgical dressings cannot establish coverability for other benefit categories such as "durable medical equipment", "prosthetics", "orthotics" or "prosthetic devices".

    For all of the above reasons, the Appellant requests a hearing by an ALJ to consider discarding the QIC's faulty determination and enabling a logical and legal determination, on the basis of submitted evidence in the case file and Medicare national policy, of the coverability of her lymphedema garments. If the ALJ feels they do not have the requisite knowledge to deal with the medical issues pertaining to lymphedema, the undersigned will be happy to provide testimony from one of many lymphedema experts who are practicing physicians in this country, at no cost to the Government.

[Appellant's signature] [Copies sent to beneficiary and to Supplier]