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Carter v. Burwell
United States District Court, W.D. Michigan, Southern Division
December 11, 2017
ROSALINE CARTER, Plaintiff,
SYLVIA MATHEWS BURWELL, Defendant.
Paul L. Maloney, J.
REPORT AND RECOMMENDATION
KENT, United States Magistrate Judge
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
Background and Administrative Action
Medicare Appeals Council (MAC) summarized plaintiff's
medical history, claim and appeal in pertinent part as
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.
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
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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