Our firm represents many Medicare beneficiaries seeking access to medical treatments and technologies. This year we are honored to be recognized by the American Bar Association for our work. The ABA’s Standing Committee on Pro Bono and Public Service works to ensure access to justice through the expansion and enhancement of the delivery of legal services to the under-served through volunteer efforts of legal professionals nationwide. Our firm has made a commitment to pro bono work.
We have been fortunate to work with many clients whose innovations have significantly improved the lives of individuals suffering from a disease or illness. We advocate for Medicare and private insurance companies to pay for those technologies and treatments through various legal and administrative channels. We have represented Medicare beneficiaries seeking access to treatments, tests and devices for various diseases and illnesses including cancer, depression, hypertension and diabetes. Our healthcare system is imperfect for those not in good health, and the cases are important not only for the individuals we are helping, but for the overall integrity of our healthcare system.
About four years ago, I was put in touch with a Medicare beneficiary, “Linda”, whose Type 1 diabetes was so profound that she was on disability. Her doctor had prescribed a continuous glucose monitor (CGM) to enable her to control her diabetes, but Medicare had denied coverage stating the device was simply precautionary. A CGM is the standard of care for individuals with Type 1 diabetes and hypoglycemic unawareness, and the primary means by which such individuals control their disease. Linda had run the five-step Medicare administrative process with only the assistance of her boyfriend, and had filed an action in District Court. We thought the case would be a single pro bono case (how hard could it be?) as we were simply arguing for her to receive the standard of care and without it she was going to the ER multiple times a month. The use of CGMs for people with Type 1 diabetes is supported by numerous published peer-reviewed papers, and more than 95% of the commercial payers cover it. Medicare coverage made economic, scientific and clinical sense. We got the denial set aside and we thought our work was done.
We started hearing from numerous Medicare beneficiaries who were asking for help because their monitors also had been denied on the basis that they were precautionary. These patients are the brave, diligent, and lucky ones – most of their contemporaries with Type 1 diabetes did not make it to Medicare age. We won numerous administrative hearings in which the majority of Medicare’s administrative judges agreed the CGM and its supplies should be covered. We also filed a policy challenge and were involved in other District Court cases. Finally, in January of this year, Medicare agreed to limited coverage for CGMs for part of each month (it will only cover 4 sensors although the sensors are only FDA approved for 6-7 days, and will not cover a CGM if a Medicare beneficiary uses a cell phone to share glucose levels with a caregiver or physician – a significant advantageous feature of a CGM). Although this is certainly progress, much more work needs to be done for patients to secure full coverage for these often life-saving devices.
We are engaged in a great national debate about healthcare. Individuals can disagree on how to fix our healthcare system, what the best system looks like, and the role of the Federal government; however, we hope all of us can agree that any healthcare system should make thoughtful, intelligent coverage decisions consistent with the opinions of expert clinicians and researchers. Each pro bono case we have taken has allowed us to work with some of the brightest, hardest working physicians who expend great personal capital on behalf of their patients, and researchers who are advancing treatment options. We meet some incredible people, who although battling a terrible disease or illness, want to be contributing members of our society and fight not only for themselves, but for others in similar situations. Although we are honored and humbled to receive this award, our greatest honor has been to serve with and for those individuals.