On December 9, 2019, Parrish Law Offices scored another victory for Medicare beneficiaries when a United States District Court ruled that Medicare Advantage Plan participants (i.e., Part C cases) have the same hearing rights as Original Medicare participants.
Parrish Law Offices routinely represents individuals and companies at all stages of the Medicare appeals process. In this capacity, Parrish Law Offices litigates claims arising under Original Medicare as well as claims submitted by Medicare Advantage Plan participants. In Original Medicare, there is a five-stage appeal process where only the first two stages (initial consideration and reconsideration) are bound by “local coverage decisions” (LCD). LCDs are guides concerning coverage promulgated by Medicare Contractors in the various regions of the United States. While controlling for the first two stages of the appeal process, LCDs are not binding on the decision makers in the third, fourth, or fifth stages (i.e., the Qualified Independent Contractor (QIC), an Administrative Law Judge (ALJ), or the Medicare Appeals Council (MAC). Thus, the QIC, ALJs, and the MAC have discretion to order coverage even if an LCD indicates an item or service is not covered. There are various reasons not to abide by an LCD, including when the LCD has not kept up with changing technology/science.
During 2019, the MAC began denying claims submitted by Medicare Advantage Plan participants on the grounds that ALJs and the MAC were bound by LCDs – only in Part C cases. Based on these MAC rulings, a number of Medicare Advantage Plans filed appeals when an ALJ declined to follow an LCD when adjudicating a Part C case. In June 2019, Parrish Law Offices filed suit in District Court in the Central District of California challenging the MAC’s interpretation of the Medicare statutes and regulations.
On December 9, 2019, the District Court found that the MAC’s ruling that an ALJ is bound to follow an LCD in a Part C case was “arbitrary and capricious.” See Maupin v. Azar, 2019 WL 7172599 (December 9, 2019) (Fitzgerald, J.). The District Court granted the Medicare beneficiary’s motion for summary judgement and dismissed the Secretary’s cross-motion for summary judgement. The Court ruled Kaiser must cover Tumor Treatment Field Therapy for a Medicare beneficiary notwithstanding an LCD that indicated Medicare would not cover the life-saving treatment.
Parrish Law Offices also challenged the LCD that asserted TTFT did not meet Medicare coverage criteria and, in July 2019, Medicare revised the LCD extending Medicare coverage of TTFT.