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Medicare Settles Suit Over Failure to Cover Eye Medication

  • June 2nd, 2003

In August 2002, ElderLawAnswers reported that three Medicare beneficiaries had sued the Bush administration because they were denied coverage for treatment of a disease that causes blindness. (See "Medicare Sued Over Failure to Set Up Appeals Process".)

The three beneficiaries suffer from a form of macular degeneration that causes occult eye lesions and can lead to blindness. The beneficiaries claimed that the only effective treatment for the disease is a drug called Visudyne. CMS initially announced that Medicare would cover the drug for this use, but in March 2002 it reversed its decision, saying the treatment is "experimental" and only "temporarily" effective. Medicare covers Visudyne to treat a different form macular degeneration.

When the three plaintiffs tried to appeal the reversal, they received word from CMS that their appeals would not be processed. This, they claimed in their suit, violates a law passed by Congress in December 2000 that required CMS to create an appeals process for national coverage decisions. Congress mandated that the appeals process be in place by October 2001.

Under the terms of the settlement, CMS will convene an outside advisory committee to consider whether Medicare should cover Visudyne to treat occult eye lesions, according to the Wall Street Journal. CMS will not have to adhere to the recommendation of the advisory committee.

Local Elder Law Attorneys in Ashburn, VA

Loretta Williams

Hale Ball Carlson Baumgartner Murphy PLC
Fairfax, VA

Evan Farr

The Law Firm of Evan H. Farr, P.C.
Fairfax, VA

Susan Pollack

Needham Mitnick & Pollack, PLC
Falls Church, VA

Last Modified: 06/02/2003

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