Favorable ALJ Ruling Based on CMN Decision

Redding, Calif.

Maximum Comfort President Tom Lambert, the California HME provider who filed suit against HHS for requiring additional documentation beyond the CMN for K0011 claims reimbursement, has now used the favorable ruling in a separate Medicare appeal.

In late June, Judge Lawrence Karlton of the U.S. District Court for the Eastern District of California ruled in a preliminary decision that properly completed CMNs are sufficient for supplier reimbursement. Lambert took that ruling to an Administrative Law Judge (ALJ) hearing involving denial of a separate power wheelchair claim in July.

On Sept. 22, ALJ Theodore Slocum ruled that the Region D DMERC’s “denial of the [K0011] claim on the basis that there was insufficient documentation showing medical necessity is without merit. In Maximum Comfort v. Sec. of U.S. Dept. of Health … the court found that a Certificate of Medical Necessity, standing alone, may be used by a provider to provide the necessary information in the determination of medical necessity and reasonableness in a reimbursement claim before Medicare.”

“I hope every dealer in the country will use [this ALJ decision] in addition to the federal court decision when they go before the ALJs to get their K0011s paid,” Lambert said.

At press time, District Judge Karlton had yet to issue a final ruling on the federal court case, and the government has 60 days to file an appeal after he does.