LCD Complaint: Knee Orthoses, DAB No. 3005 (2020)

FINAL DECISION ON REVIEW OF ADMINISTRATIVE LAW JUDGE DECISION

Complainant, a Medicare beneficiary, challenged a Medicare coverage policy, called a Local Coverage Determination (LCD), under 42 C.F.R. Part 426, which authorizes the Departmental Appeals Board and its administrative law judges (ALJs) to review the validity of LCDs issued by Medicare program contractors.  Complainant seeks review of the ALJ's decision to dismiss his amended complaint challenging LCD L33318, Knee Orthoses.  Acknowledgment of Receipt of Acceptable Complaint as to LCD L35427, Order to File Record for LCD L35427, and Briefing Schedule; and Dismissal of Complaint as to LCD L33318, CRD Docket No. C-20-2431 (Dec. 12, 2019) (ALJ Dismissal).  The ALJ dismissed as unacceptable the amended complaint as to LCD L33318 based on his determination that it did not contain a treating physician's statement that demonstrates the medical necessity of new custom-fabricated bilateral knee orthoses (knee braces).  For the reasons set forth below, we affirm the ALJ's dismissal.

Legal Background

Section 1869(f)(2) of the Social Security Act and the regulations at 42 C.F.R. Part 426 permit Medicare beneficiaries denied coverage for items or services on the basis of an LCD to challenge the validity of the LCD by filing an "LCD complaint" before an ALJ.  42 C.F.R. §§ 426.110, 426.320, 426.400; see generally 42 C.F.R. Part 426, subparts C, D. After an LCD complaint is docketed, the ALJ evaluates whether the complaint is "acceptable."  Id. § 426.410(b).  In order to be acceptable, an LCD complaint must meet

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the requirements for a valid complaint in section 426.400 (id. § 426.410(b)(2)), which include, among other things, a "copy of a written statement from the treating physician that the beneficiary needs the service that is the subject of the LCD."  Id. § 426.400(c)(3).  The statement "may be in the form of a written order for the service or other documentation from the beneficiary's medical record (such as progress notes or discharge summary) indicating that the beneficiary needs the service."  Id.

If the ALJ determines that the complaint is unacceptable, the ALJ must provide the beneficiary an opportunity to amend the complaint "within a reasonable timeframe as determined by the ALJ."  Id. § 426.410(c)(1), (c)(2).  If the ALJ later determines that the amended complaint is unacceptable, the ALJ must issue a decision dismissing that complaint.  Id. § 426.410(c)(2).  The beneficiary may then appeal the dismissal to the Board within 30 days of the date of the dismissal.  Id. § 426.465(a)(2), (e).  The standard of review that the Board applies is "whether the ALJ decision [dismissing the complaint] contains any material error."  Id. § 426.476(b)(1).

Case Background

Complainant2 requested ALJ review of two LCDs, Knee Orthoses (LCD L33318) and Hyaluronan Acid Therapies for Osteoarthritis of the Knee (LCD L35427), pursuant to 42 C.F.R. Part 426.  ALJ Dismissal at 2; Request for LCD review at 1.  Complainant also requested review regarding the availability of platelet rich plasma injections, which he acknowledged were not covered under any LCD.  ALJ Dismissal at 2; Request for LCD review at 1.  Regarding LCD L33318, Complainant stated that he was "requesting replacement of [his] existing custom fabricated Bi Lateral orthosis braces every three years for both knees."  Id.  Complainant also stated that he was no longer qualified to receive new knee braces because the challenged LCD requires a beneficiary "to have a recent injury to or surgical procedure on the knees."  Id.  Complainant explained that he does not have a recent injury and that he cannot have surgery on both knees due to comorbidities.  Id.

The ALJ issued an acknowledgment letter in which he stated that Complainant's request was "not an acceptable complaint."  Acknowledgment Letter at 2.  The ALJ explained that Complainant "must be an aggrieved party within the meaning of the regulations."  Id. at 3.  As the ALJ also explained, to be an "aggrieved party," Complainant must be entitled to Medicare benefits, in need of the service or equipment denied based on an applicable LCD, and have documentation of need by the Complainant's (beneficiary's) treating physician.  Id.; 42 C.F.R. § 426.110 (defining "Aggrieved party").  The ALJ

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found that Complainant "failed to submit documents showing that a Medicare contractor denied coverage or would deny coverage for the necessary equipment based on an LCD within the 120 days preceding" the filing of the complaint.  Acknowledgment Letter at 3.  The ALJ also found that Complainant "failed to submit any clinical or scientific evidence that shows why [Complainant] believe[d] that a determination not to provide coverage is unreasonable."  Id. (citing 42 C.F.R. § 426.400(c)(6)).  The ALJ explained that section 426.410(c) permits a single opportunity to "correct [the] unacceptable complaint," and that section 426.410(c) "required" him to dismiss the case if Complainant failed to do so.  Id.  The ALJ informed Complainant that his "amended complaint must satisfy all the requirements for an acceptable complaint specified at 42 C.F.R. § 426.400."  Id.

In response, Complainant filed an amended complaint and eight exhibits (P. Exs. 1-8), which included a July 30, 2019 letter from his treating physician, Dr. T.W., stating that Complainant needs hyaluronic acid injections every three months (P. Ex. 1).  ALJ Dismissal at 4.  The ALJ subsequently issued the dismissal, determining that the complaint as to LCD L35427 was acceptable.  Id. at 3.  The ALJ also determined that the complaint as to the platelet rich plasma injections had been withdrawn.  Id.  However, the ALJ determined that the amended complaint as to LCD L33318 must be dismissed as unacceptable because it did not include a treating physician's statement of medical necessity in accordance with section 426.400(c)(3).  Id. at 4.  The ALJ found that the July 30, 2019 physician statement, P. Ex. 1, related to the need of hyaluronic acid injections and, while it mentioned the use of bracing as part of "management strategies," it did not state that Complainant was "in need of new braces."  Id.  The ALJ explained that he gave Complainant an opportunity to submit an acceptable (amended) complaint,3 which Complainant did not do, and he was therefore required to dismiss the complaint pursuant to section 426.410(c)(2).  Id.  The ALJ notified Complainant that he was precluded from filing a new complaint regarding LCD L33318 for six months.  Id. (citing 42 C.F.R. § 426.410(c)(3)).

Complainant timely filed this appeal.

Discussion

Before the Board, Complainant argues that the ALJ committed a material error in determining that he had not submitted an acceptable amended complaint that included the requisite treating physician's statement of medical necessity of new braces.  Complainant

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points to a July 3, 2019 email from an individual at the office of Complainant's treating physician (Dr. T.W.) to Complainant as evidence of a doctor's determination of medical necessity.  Complainant's Appeal (CA)4 at 15, 18; P. Ex. 2, at 1.  In the email, the individual stated that she wrote to the supplier's representative "regarding the bilateral knee braces," but had not yet received a response.  P. Ex. 2, at 1.  We see nothing in the July 3, 2019 email or elsewhere in the record on which the ALJ issued his dismissal that the author of the email is a physician.  That aside, the email says nothing about medical necessity.  It merely indicates that the author of the email contacted the supplier about the braces.5

Moreover, Complainant does not raise any argument concerning the ALJ's finding that the July 30, 2019 physician statement, P. Ex. 1, did not prove that Complainant required new knee braces because it mentioned "management strategies" that included the use of bracing, but did not state that Complainant was "in need of new braces."  ALJ Dismissal at 4.  Nor does the record on which the ALJ issued his dismissal include any medical records, such as progress notes, that demonstrate the medical necessity of new bracing.  See 42 C.F.R. § 426.400(c)(3) (requisite evidence of medical necessity may be established based on "documentation from the beneficiary's medical record" indicating medical need).  We therefore find no error in the ALJ's conclusion, based on the record before the ALJ, that Complainant had failed to submit a valid, acceptable complaint.6

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Complainant now offers the Board a January 7, 2020 letter from Dr. T.W., who wrote that, although "recent guidelines to [M]edicare disqualifies [Complainant] for bracing," Complainant has been wearing braces for some time and should have "replacement" braces every three years beginning in 2020.  CA at 14.  This letter – written two months after the date the ALJ permitted for submittal of a valid amended complaint, November 4, 2019 – comes too late.  As the ALJ explained, he was required to dismiss a complaint as unacceptable if, after one opportunity to amend it "within a reasonable timeframe as determined by the ALJ" (42 C.F.R. § 426.410(c)(2)), Complainant failed to amend it to make the complaint an acceptable one.  Acknowledgment Letter at 3.  The ALJ also explained that the amended complaint must satisfy 42 C.F.R. § 426.400 (id.), which states that requisite evidence of medical necessity is one of several requirements of a valid, acceptable complaint.

Complainant does not assert that the time period the ALJ gave him to amend his complaint to make it a valid, acceptable one – almost one month from the date of the ALJ's Acknowledgment Letter – was unreasonable.  He does not state that he was unable to obtain a letter from Dr. T.W., his treating physician, before November 4, 2019, for any reason.7  Nor do we see anything in the record of the ALJ proceedings or in Complainant's submission to the Board that causes us to question whether Complainant was aware of what he needed to submit to the ALJ and when he must do so.  The ALJ did not err in dismissing the amended complaint as unacceptable for failure to include the requisite evidence of medical necessity despite the opportunity to correct the complaint.  By regulation, the ALJ was required to do so under the circumstances.

Lastly, we note that the ALJ informed Complainant that he had not established that he is an "aggrieved party" consistent with the definition in 42 C.F.R. § 426.110 because he "failed to submit documents showing that a Medicare contractor denied coverage or would deny coverage for the necessary equipment based on an LCD[.]"  Acknowledgment Letter at 3.  The ALJ Dismissal did not address whether the amended complaint established that Complainant met the regulatory definition of an "aggrieved party" as it relates to his challenge of LCD L33318.  But we find no material error based on the ALJ's not having addressed specifically whether Complainant met the regulatory definition of an "aggrieved party" because the basis on which the ALJ dismissed the

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amended complaint was itself legally sound.  42 C.F.R. § 426.476(b)(1).  We observe that one element of the regulatory definition of an "aggrieved party" is that the beneficiary "[h]as obtained documentation of need by the beneficiary's treating physician" (42 C.F.R. § 426.110) – the very evidence Complainant failed to submit to the ALJ by November 4, 2019 to support a valid, amended complaint.

Conclusion

We uphold the ALJ's dismissal of the amended complaint as to LCD L33318.  Pursuant to 42 C.F.R. § 426.410(c)(3), Complainant may file another complaint "6 months after being informed" that his complaint was unacceptable.