Lawsuit Over CMS Medicare Appeals Process Settled

May 29, 2003
The Centers for Medicare and Medicaid Services (CMS) has settled a lawsuit over a decision by Medicare not to cover a medication for a form of macular degeneration that causes occult eye lesions and can lead to blindness, the Wall Street Journal reported.

Under the terms of the settlement, CMS will convene an outside advisory committee to consider whether Medicare should cover Visudyne to treat occult eye lesions; it now covers the medication to treat a different form of macular degeneration. CMS will not have to adhere to the recommendation of the advisory committee.

Last August, three Medicare beneficiaries and three senior advocacy groups filed a lawsuit in a Washington, D.C., federal court against CMS over allegations that the agency did not allow them to appeal a decision to end Medicare coverage for Visudyne to treat occult lesions. CMS approved coverage for Visudyne to treat occult lesions in October 2001 but reversed the decision in March 2002.

The three beneficiaries said that they filed an appeal of the March decision but that CMS did not act on the appeal -- an alleged violation of a law passed by Congress in December 2000 that requires CMS to establish an appeals process for certain coverage decisions. Congress mandated that CMS have the process in place by October 2001.

The lawsuit asked the court to force CMS to comply with the law. CMS officials argued that the agency did not have the regulations in place to act on such an appeal.