Well, this beats everything.

Oh, just to clarify, his Medicare HMO PAID FOR CUSTOM SHOES WITH CUSTOM ORTHOTICS FOR 2 YEARS, but in 2009, they paid for the shoes but not for the orthotics.

About two weeks ago, we had a telephone hearing with the Administrative Law Judge because we appealed the Medicare HMO's decision not to pay for Alan's custom orthotics (inserts)

The ALJ listed to all sides and the insurance company admitted paying for the shoes, also admitted they made a mistake and SHOULD NOT HAVE PAID FOR THE SHOES in 2009, and SHOULD NOT HAVE PAID FOR BOTH SHOES AND INSERTS in 2007 and 2008.

So we are all on the phone trying to get the judge to order Alan's medicare HMO to pay for the Orthotics.

Alan also needs new shoes for THIS YEAR.

At the time, the judge seemed VERY sympathetic to Alan's cause and even asked the insurance company "let me get this straight, you are denying Alan's orthotics because he is NOT a diabetic, but you acknowledge that NEUROPATHY in either case is the same disorder.

The other side said "yes, but we have to go by medicare guidelines".

I really thought I had the judges ear and hoped that he would over-ride that medicare guideline thing.

Well, this is what the last paragraph of the decision letter said. (On the first page it indicates that the decision is UNFAVORABLE).

Get a load of this paragraph. and the next!!!

---------------------------------------------------------------------

"the undersigned ALJ understands that it must be very frustrating to know that Medicare will cover custom shoes and inserts for diabetic neropathy, but not for peripheral neuropathy, as such a limitation places form over substance. The undersigned, however is bound by the legislatively created exclusion of orthotic shoes and inserts from Medicare coverage, unless to treat diabetic neuropathy.
Conclusions of Law
The applicable laws, regulations, policies and contracts do not obligate the Plan to cover the items at issue in this appeal. Section 1862(a)(8) of the Act, NCD No. 280.10 and the Plan's Evidence of Coverage exclude Medicare coverage of orthopedic shoes, inserts, or other supportive devices for the feet. The Appellant does not qualify for an exception to such exclusion because he does not have diabetic neuropathy.

Order
The appeal is denied. An unfavorable decision is entered for the Appellant.


Now in the first pages, it does say that he can appeal this whole thing. There is a form Called Request for Review of Administrative Law Judge (ALJ) Medicare Decision/Dismissal

So our next step would be to APPEAL THIS DECISION, RIGHT?

Would any of you do this?

I mean, here's my question.

IF THE JUDGE SAID HE HAD TO FOLLOW THE MEDICARE GUIDELINES, WHY THE HECK DID WE HAVE TO HAVE A HEARING IN THE FIRST PLACE??????????????????????????

Any comments are welcome.

melody