At the request of a coalition of groups led by advocates for people with disabilities, the Health Care Financing Administration (HCFA) has reversed a non-coverage determination, Medicare Coverage Manual ' 60-9 (DME Reference List), which had classified augmentative and alternative communication devices (ACDs) as convenience items not covered by Medicare. ACDs are used by people with severe speech impairments to assist them in communicating. Under the decision issued April 26, 2000, ACDs will be classified as durable medical equipment (DME) subject to Medicare coverage rules. HCFA did not go as far as requested by the disability organizations, however, and did not issue a national coverage determination providing for coverage in all situations. Instead, the decision allows local Medicare carriers to issue local medical coverage policies concerning coverage of ACDs pending further HCFA fact-gathering.
Before the April decision, administrative law judges (ALJs) faced with applying the non-coverage determination to ACDs routinely found that Medicare Coverage Manual ' 60-9 did not apply. The ALJs agreed with advocates= arguments that ACDs were not convenience items subject to the non-coverage determination, but were durable medical equipment that helps treat severe communication disorders.
The April decision represents a significant victory for advocates in that HCFA seldom responds to their requests to change a national coverage determination. However, it points out some problems in HCFA=s process for issuing national coverage determinations. For example, the process takes too long. Although HCFA guidelines state that the agency will aim for issuing a decision within 90 days from the date a request is accepted, HCFA was a month late in issuing the decision in this non-complicated case. The burden of proof required by HCFA before issuing a national coverage determination may also be too high. HCFA found the substantial evidence submitted by the requestors to be Asuggestive of the utility of these devices for those with severe speech impairments.@ Nonetheless, HCFA stated the requestors did not offer sufficient medical evidence of outcomes and patients who would be benefited to allow HCFA to issue a national coverage determination at this time. They would like additional evidence, particularly from those health care professionals most likely to treat patients with severe speech impairments, before issuing a positive national coverage determination.
Copyright © Center for Medicare Advocacy, Inc. 01/08/2010