This past year there were twelve Medicare Appeals Hearings seeking Medicare payment for MAT treatments provided by ADRI. Each hearing involved several different Appeals, making a total of 81 Appeals. Administrative Law Judges (ALJs) in each of these Appeals ruled that Medicare is not required to pay for MAT. This is a marked change from previous years.
National Heritage Insurance, Medicare Part B contractor for California, has long denied payment for MAT. However, prior to July 2005, these denials were successfully appealed through the ALJ Medicare Appeal Hearings process, resulting in a total of 125 consecutive favorable decisions.
Beginning in October 2005, ALJs in the Medicare Appeals Hearings began denying Medicare payment for MAT despite no change in the regulations or the therapy. Many cases are the very same patients approved in Medicare Appeal Hearings the year before. In response to the negative ALJ rulings, both patients and ADRI have forwarded appeals to the U.S. Department of Health and Human Services (HHS). A number of these further appeals have already been reviewed and rejected by HHS.
These patients had severe diabetic complications which were becoming progressively worse despite the most intensive diabetes therapy recommended by the American Diabetes Association. In every case, their complications slowed, improved or stabilized while receiving weekly MAT treatments. With Medicare no longer paying for their MAT treatments, these patients are faced with a very difficult financial dilemma.