Medicare Appeals Council Decisions

In January 2003, the Medicare Appeals Council (MAC) initiated the posting of certain significant decisions and actions on the web site of the Departmental Appeals Board (of which it is a component). The following decisions and actions were selected for posting since they involve the adjudication of issues that may be of interest to various stakeholders in the Medicare appeals process. They are indexed by primary topic area. This compendium of MAC decisions will be supplemented periodically.

Cases with an asterisk (*) were later appealed to the federal courts. The reader may wish to research any subsequent action by the courts.

TOPIC AREA

Requests for Escalation
In the case of General Medicine, P.C., (September 6, 2007)

Advance Beneficiary Notification (ABN)/ Notice of Noncoverage
In the case of Connecticut Department of Social Services, (January 11, 2008)
In the case of Country Manor Health Care, (January 17, 2003)

Administrative Law Judge Hearings
In the case of Atlantic Anesthesia Associates, P.C., (June 17, 2004)
In the case of Marshall Lane Manor (November 25, 2005)

Ambulance Cases
In the case of Gold Cross Ambulance (September 28, 2009)
In the case of Air Evac EMS (October 14, 2009)
In the case of D.C. (November 17, 2009)

Amount in Controversy
In the Case of International Rehab. Sciences (April 8, 2009)
In the case of M.F., (June 17, 2004)

Blood Glucose Testing
In the Case of Crystal Lake Healthcare and Rehabilitation Center, (February 15, 2007)

Dental Services
In the case of C.S. (December 21, 2000)
In the case of First Priority 65 (January 16, 2002)
In the case of W.J. (March 22, 2004)

Durable Medical Equipment (DME)/ Certificate of Medical Necessity (CMN)
In the case of Maximum Comfort, Inc. (June 11, 2003)*
In the case of The Scooter Store (December 2, 2004)

Durable Medical Equipment (DME)/National Coverage Determination (NCD)
In the case of Prime Medical. (September 27, 2004)

Equal Access to Justice Act (EAJA)
In the Case of John Handron, Ph.D (May 22, 2008)

General Claim Requirements Cases
In the case of International Rehab Sciences, Inc. (April 8, 2009)
In the case of Health & Oncology Services (September 21, 2009)
In the case of Philip B. Khoury, M.D. (October 2, 2009)
Robert Markman M.D. (October 21, 2009)
In the case of Breton L. Morgan, M.D. (November 5, 2009)

Home Health Services
In the Case of G.R. (October 15, 2007)

Hospital Inpatient Claims
In the Case of O'Connor Hospital (February 1, 2010)

"Incident To" Services/Waiver of Overpayment Recovery
In the Case of Comprehensive Decubitus Therapy (March 13, 2009)
In the case of Gary W. Gibbon, M.D.*

Medicare Advantage Program/Non-Participating Physician Charges
In the case of O.G. (September 17, 2005)

Medicare Appeals Council Jurisdiction/Amount of Payment
In the case of M.G. (July 18, 2003)

Medicare+Choice Program/Ambulance Services
In the case of E.W. (November 13, 2003)

Medicare+Choice Program/Disenrollment
In the case of Fallon Community Health Plan (October 16, 2003)

Medicare+Choice Program/Drug Coverage
In the case of PacifiCare/Secure Horizons (July 26, 2001)
In the case of Blue Shield of California (June 20, 2002)
In the case of Pacificare/Secure Horizons (November 28, 2004)

Medicare+Choice Program/ Post-Stabilization Care
In the case of C.G. (May 20, 2003)

Non-Physician Services
In the case of Michael H. Quinn, D.P.M. (June 20, 2001)*

Parenteral-Related Supplies/Carrier Jurisdiction
In the case of Key Largo Medical Systems et al., (April 5, 2002)

Peer Review Organization (PRO) Review of Hospital Services
In the case of Niobrara Valley Hospital (March 27, 2003)

Physician Billing and Payment/Assistant at Surgery
In the case of The Hand Care Center (Amended Decision), (July 1, 2003)

Physician "Opt Out" of Medicare/Private Contracts With Beneficiaries
In the case of R.G. (April 2, 2003)

Reopening/Outpatient Billing
In the case of Critical Care of North Jacksonville (February, 29, 2008)
In the case of Providence St. Joseph Medical Center (July 23, 2008)
In the case of Memorial Hospital of Long Beach (July 23, 2008)

In the case of UMDNJ (March 14, 2005)

Right to In-Person Hearing
In the case of New Jersey Dept. of Human Services (April 24, 2006)

Services Outside the United States/Estoppel
In the case of I.W.B. (May 2, 2001)

Skilled Nursing Facility - Prospective Payment System
In the case of Evansville Manor (June 28, 2004)

Statistical Sampling
In the case of Samuel Nigro.M.D. (April 30, 2001)
In the case of Metro Home Care (December 17, 2001)
In the case of Vascular Diagnostic Center and Vascular Testing Center (April 17, 2003)