Part B Insider (Multispecialty) Coding Alert

Published on Thu Sep 20, 2007 PDF

Beneficiaries must continue to jump through Part D's administrative appeals hoops when prescription drug plans deny coverage of needed drugs.

A cancer patient who claims that her Medicare Advantage plan improperly classified her chemotherapy drugs must first exhaust her administrative remedies under Medicare before she can seek judicial review of her claims. That decision was handed down last month from a federal district court in Florida (Masey v. Humana Inc., M.D. Fla. No. 06-1713).

In cases in which a party's claims are -inextricably intertwined- with a claim for Medicare benefits, judicial review is not available until the party has presented his claims to the Dept. of Health and Human Services and run through all options in the administrative appeal process, wrote Judge Elizabeth Jenkins, writing for the District Court for the Middle District of Florida on Aug. 16.

Darly Masey alleged in the case that Humana breached its Medicare Advantage contract when it classified her chemotherapy drugs as covered by Part D rather than Part B. Part B would have covered 100 percent of the associated costs, but Masey incurred -thousands of dollars- in drug expenses under Part D.