Source: http://www.scribd.com/doc/227212239/DAB-No-2576-NCD-140-3-Transsexual-Surgery
Timestamp: 2015-07-04 19:40:05
Document Index: 592792970

Matched Legal Cases: ['§ 426', '§ 426', '§ 1395', '§ 1862', '§ 400', '§ 405', '§ 405', '§ 1869', '§ 426', '§ 426', '§ 426', '§ 426', '§ 426', '§ 426', '§ 426', '§ 426', '§ 426', '§ 426', '§ 426', '§ 426', 'art 426', '§ 426', '§ 426', '§ 426', '§ 426', '§ 426', '§ 426', '§ 426', 'art 426']

P. 1DAB No. 2576 - NCD 140 3 Transsexual SurgeryDAB No. 2576 - NCD 140 3 Transsexual SurgeryRatings: 5.0 (1)|Views: 14,354|Likes: 0Published by EvanMcSanDAB RulingDAB RulingMore info:Published by: EvanMcSan on May 30, 2014Copyright:Traditional Copyright: All rights reservedAvailability:Read on Scribd mobile: iPhone, iPad and Android.download as PDF, TXT or read online from ScribdFlag for inappropriate content|Add to collectionSee moreSee lesshttps://www.scribd.com/doc/227212239/DAB-No-2576-NCD-140-3-Transsexual-Surgery01/05/2015pdftextoriginal Department o Health and Human Services DEP RTMENT L PPE LS BO RD ppellate Division NCD 140.3, Transsexual Surgery Docket No. A-13-87 Decision No. 2576 May 30, 2014 DECISION The Board has determined that the National Coverage Determination (NCD) denying Medicare coverage of all transsexual surgery s a treatment for transsexualism is not valid under the reasonableness standard the Board applies. The NCD was based on information compiled in 1981. The record developed before the Board in response to a complaint filed by the aggrieved party (AP), a Medicare beneficiary denied coverage, shows that even assuming the NCD's exclusion of coverage at the time the NCO was adopted was reasonable, that coverage exclusion is no longer reasonable. This record includes expert medical testimony and studies published in the years after publication of the NCO. The Centers for Medicare Medicaid Services (CMS), which is responsible for issuing and revising NCDs, did not defend the NCD or the NCO record in this proceeding and did not challenge any of the new evidence submitted to the Board. Effect o this decision Since the NCD is no longer valid, its provisions are no longer a valid basis for denying claims for Medicare coverage of transsexual surgery, and local coverage determinations (LCDs) used to adjudicate such claims may not rely on the provisions of the NCD. The decision does not bar CMS or its contractors from denying individual claims for payment for transsexual surgery for other reasons permitted by law. Nor does the decision address treatments for transsexual ism other than transsexual surgery. The decision does not require CMS to revise the NCD or issue a new NCD, although CMS, of course, may choose to do so. CMS may not reinstate the invalidated NCD unless it has a different basis than that evaluated by the Board. 42 C.F.R. § 426.563. CMS must implement this Board decision within 30 days and apply any resulting policy changes to claims or service requests made by Medicare beneficiaries other than the AP for any dates of service after that implementation. With respect to the AP s claim in 2 particular, CMS and its contractors must adjudicate the claim without using the provision(s) of the NCO that the Board found invalid. 42 C.F.R. § 426.560(b ) 1 ).
egal background With exceptions not relevant here, section 1862(a)(l)(A) of the Social Security Act (Act) ( 42 U.S.C. § 1395y(a)(l)(A)) bars Medicare payment for items or services not reasonable and necessary for the diagnosis or treatment of illness or injury[.] 2 CMS refers to this requirement as the medical necessity provision. 67 Fed. Reg. 54,534, 54,536 (Aug. 22, 2002). An NCO is a determination by the Secretary [of Health and Human Services] with respect to whether or not a particular item or service is covered nationally under [title XVIII (Medicare)]. Act§§ 1862(1)(6)(A),1869(f)(l)(B); see also 42 C.F.R. § 400.202 (NCO means a decision that CMS makes regarding whether to cover a particular service nationally under title XVIII of the Act. ). NCOs describe the clinical circumstances and settings under which particular [Medicare items and] services are reasonable and necessary (or are not reasonable and necessary). 67 Fed. Reg. at 54,535. When CMS issues NCOs, they apply nationally and are binding at all levels of administrative review of Medicare claims. 42 C.F.R. § 405.1060. CMS and its contractors use applicable NCOs in determining whether a beneficiary may receive Medicare reimbursement for a particular item or service. 42 C.F.R. §§ 405.920, 405.921. A Medicare beneficiary in need of coverage for a service that is denied based on ... an NCO is an aggrieved party who may challenge the NCO by filing a complaint with the Board.
3 Act§ 1869(f)(l ); 42 C.F.R. §§ 426.110, 426.320. The complaint must comply with the requirements for a valid complaint in 42 C.F.R. § 426.500 in order to be accepted by the Board. 42 C.F.R. §§ 426.510(b )(2), 426.505(c)(2). After the Board notifies CMS of the receipt of a complaint that is acceptable under the regulations, CMS produces the NCO record, which consists of any document or material that CMS 1 ee generally 42 C.F.R. § 426.560(b) (setting out the effects of a Board NCO decision); 42 C.F.R. § 426.555 (specifying what the Board's decision may not do ). This decision has no effects beyond those set out in 42 C.F.R.§ 426.560(b) and does not impose on CMS or its contractors any orders or requirements prohibited by 42 C.F.R. § 426.555. 2 The table of contents to the cunent version of the Social Security Act, with references to the conesponding United States Code chapter and sections, can be found at http://www.socialsecurity.gov/OP Home/ssact/ssact-toc.htm. 3 The regulations also provide that a person other than the aggrieved party with an interest in the issues may petition to participate in the review process as an amicus curiae. 42 C.F.R. §§ 426.51 O f), 426.513. The Board posts on its website notice of the NCO complaint specifying a time period for requests to participate in the review. 42 C.F.R. § 426.51 O f). 3 considered during the development of the NCD including medical evidence considered on or before the date the NCD was issued 42 C.P.R.§§ 426.510(d)(3), 426.515, 426.518(a). The aggrieved party submits a statement explaining why the NCD record is not complete, or not adequate to support the validity of the NCD under the reasonableness standard, and CMS may submit a response in order to defend the NCD. 4 C.P.R. § 426.525(a), (b). If the Board determines that the NCD record is complete and adequate to support the validity of the NCD, the review process ends with the Board's [i]ssuance of a decision finding the record complete and adequate to support the validity of the NCD 4 C.P.R. § 426.525(c)(l), (2). If the Board determines that the record is not complete and adequate to support the validity of the NCD, the Board permits discovery and the taking of evidence and evaluates the NCD in accordance with the requirements of Part 426, including conducting a hearing, unless the matter can be decided on the written record. 4 C.P.R. §§ 426.525(c)(3), 426.531(a)(2). Prior to issuing a decision, the Board must review any new evidence admitted to the record before the Board and determine whether it has the potential to significantly affect the Board's evaluation. 42 C P R §§ 426.340(a), (b), 426.505(d)(3). New evidence is defined as clinical or scientific evidence that was not previously considered by ... CMS before the ... NCD was issued. 42 C.P.R. § 426.110. If the Board so concludes, the Board stays proceedings for CMS to examine the new evidence, and to decide whether [to] initiate[] ... a reconsideration of the NCD. 42 C.P.R.§ 426.340(d). If CMS does not reconsider the NCD, or reconsiders it but does not change the challenged provision, the Board lifts the stay and the NCD challenge process continues. 42 C.P.R. § 426.340(f). At the end of that process, the Board closes the record and issues a decision that the challen,red provision of the NCD is valid or is not valid under the reasonableness standard. 4 C.P.R.§ 426.550. The Board's decision constitutes a final agency action and is subject to judicial review on appeal by an aggrieved party. 4 C.P.R. § 426.566. 4 Section 426.547(b) states that the Board must make the decision available at the HHS Medicare Internet site and that the posted decision does not include any information that identifies any individual, provider of service, or supplier. CMS has indicated in the preamble to the Part 426 regulations that this provision was meant to protect the privacy of Medicare beneficiaries such as the AP. See e.g. 68 Fed. Reg. 63,692,63,708 (Nov. 7, 2003) ( Board decisions regarding NCDs will be made available on the Medicare Internet site, without beneficiary identifying information ). Activity (13)FiltersAdd to collectionReviewAdd NoteLikeShowingAllMost RecentReviewsAll NotesLikesYou've already reviewed this. Edit your review.Rating 0/5Post notePost reviewPost replyPost note and likeLoad more
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