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Carter v. Burwell

United States District Court, W.D. Michigan, Southern Division

December 11, 2017

ROSALINE CARTER, Plaintiff,
v.
SYLVIA MATHEWS BURWELL, Defendant.

          Hon. Paul L. Maloney, J.

          REPORT AND RECOMMENDATION

          RAY KENT, United States Magistrate Judge

         Plaintiff brings this action seeking judicial review of administrative decisions denying her Medicare claim for dental services. See Compl. (ECF No. 1). This matter is now before the Court on defendant's motion for summary judgment (ECF No. 16).

         I. Background and Administrative Action

         The Medicare Appeals Council (MAC) summarized plaintiff's medical history, claim and appeal in pertinent part as follows:

The beneficiary's medical history was significant for a 2009 diagnosis of an oral sarcoidosis lesion. See Exh . 4 at 15. Oral sarcoidosis is an autoimmune disease. Following consultations with an oral surgeon, oral pathologist and periodontist at a public university . . . the beneficiary was referred to the ultimate provider of the services in issue -- J.C.D., D.D.S. Id. Dr. J.C.D. recounted that the beneficiary -
. . . was being seen at out office every 6 months for perioprophy and at . . . [the University] for the lesion. No treatment for the sarcoidosis lesion was being recommended at . . . [the University] so I referred her to a periodontist.
Upon examination [tooth] #9 . . . had external root resorption and required extraction. A flipper was mad[e] to replace this tooth.
Later . . . a free gingival graft #10-12 was performed. This tissue responded favorably but the lesion was still present.
During a follow- up visit . . . #8 had root resorption and was hopeless. Due to the lesion in the area a tissue borne prosthesis (RPO) was not recommended. Also due to the lesion imp[l]ants were not recommended since the abutments would be directly in the affected area. Therefore a fixed bridge was the best long term solution.
#8 was extracted and teeth #6, 7, 10, 11, 12 were prepared for the bridge . . . The tissue has responded favorably in the edentulous area (#8 and 9) while some redness remains on the maxillary left side.

PageID.146-147.[1]

         After performing the procedure:

Dr. J.C.D. apparently did not accept assignment, so the beneficiary filed a Medicare claim with multiple service lines; five utilizing HCPCS code 06752 (crown-porcelain fused to noble metal) and two utilizing HCPCS code 06242 (pontic-porcelain fused to noble metal). See Exh. 4 at 32. Identifying each claim line as having been billed under HCPCS code 06752, the Medicare contractor denied coverage, initially and upon redetermination, noting that the 06752 service was specifically identified, in the Medicare Physicians Fee Schedule Data Base (MPFSDB), as not covered. The contractor held the beneficiary liable for the associated non-covered costs.

PageID.147-148.

         Plaintiff sought reconsideration of the denial of coverage:

Upon reconsideration, the Qualified Independent Contractor (QIC) also denied coverage. The QIC distinguished between the two HCPCS code billed but, like the contractor, explained that these procedures were services “identified, by the Centers for Medicare and Medicaid Services (CMS), as . . . non-covered or excluded from coverage under the Medicare program . . . based on the code status “N” as shown on ...

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