From: (redacted)
Sent: Saturday, February 28, 2015 9:58 AM
To: Herbert Stein
Subject: RE: DECISION THAT THE NCD RECORD IS COMPLETE AND ADEQUATE TO SUPPORT THE VALIDITY OF NCD 160.18(C), VAGUS NERVE STIMULATION
Hi Herbert.
Got your call and the email updates. Thank you.
I take it from the document, this decision is not overturning the 2013 to cover battery replacement but rather rejects the argument that the previous decision to stop coverage of new implants was not based on full record of evidence. Is this your thoughts?
I am working with a case manager at Cyberonics and I am awaiting a predetermination of benefits. I expect it will be denied. I have starting collecting all my medical records. Also I have started a draft of a personal statement.
My next step will be to find the direct contact info of Florida Blues CEO.
I will keep you up yo date if how this transpires.
Again thank you for your continued support to all if us.
Sincerely
(Redacted)
Sent from my Windows Phone
From: Herbert Stein [Redacted]
Sent: Saturday, February 28, 2015 12:57 PM
To: (Redacted)
Subject: RE: DECISION THAT THE NCD RECORD IS COMPLETE AND ADEQUATE TO SUPPORT THE VALIDITY OF NCD 160.18(C), VAGUS NERVE STIMULATION
(Redacted),
My understanding of this recent appeal decision is that they are upholding the May 4, 2007 decision to not pay for any implants or care of new patients on or after that date.
While denying insurance coverage to new patients it goes on further to state for the first time in this recent appeal decision, in writing, the care and replacement of the device rightfully for Medicare/Medicaid patients implanted prior to May 4, 2007 under the doctrine or law of “continuity of care”. I further interpret this decision to mean that the private health insurers, who normally follow CMS’s lead, should also follow the “continuity of care” doctrine as quoted below:
(1) “continuity of care” standards that are “widely accepted within the medical community (i.e., a physician should not discontinue treatment that is effective for a patient)”; (2) “well-accepted medical standards of care that acknowledge that it is unsafe for beneficiaries to have an implanted medical device that is not properly calibrated, monitored, or is otherwise non-functional”; and (3) “CMS policy statements wherein CMS has recognized that continuing Medicare coverage for beneficiaries who received Medicare-covered durable medical equipment (DME) before it was non-covered ‘helps avoid disrupting the continuity of care for the beneficiaries . . . .’” Id. ¶¶ 40-42 (quoting 78 Fed. Reg. 40,836, 40,877 (July 8, 2013)).
Not being a legal authority I can only express my opinion based upon my readings but were I in your position I certainly would emphasize and strongly hang my hat on the above information and decisions to encourage, enforce and coerce your insurance carrier to relent and do the right thing.
If you’re able to obtain an email address for Florida Blue CEO I’ll jump immediately on advocating for your cause.
I’m here and available to encourage and support your efforts.
Sincerely,
Herb
Joyce and Herbert Stein
1008 Trailmore Lane
Weston, FL 33326-2816
(954) 349-8733
http://www.vnstherapy-herb.blogspot.com
http://www.vnstherapy.wordpress.com
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