University Times

Work done at the Pitt Health Law Clinic has sparked a review of Medicare procedures that could have an impact on diabetics nationwide.

Thanks to the law clinic’s work on behalf of a UPMC patient in need of a pancreas transplant, Medicare is reconsidering its policy of refusing coverage for most pancreas transplants. Under a 1995 National Coverage Decision (NCD), Medicare covers pancreas transplants for diabetes patients only in conjunction with or after a kidney transplant. At the time, Medicare administrators were not convinced that pancreas transplants had been proven effective and successful.

The law clinic, under the supervision of attorney Stella Smetanka, filed a petition challenging the NCD on behalf of Sharon Reigh of State College.

The health law clinic is one of several law clinics at Pitt. Others focus on elder law, environmental law, family law, community economic development or tax law.

Under the supervision of an attorney and with the approval of the Pennsylvania Supreme Court, students are allowed to practice law in a limited number of cases on behalf of low-income clients.

Students in the for-credit health law clinic course work in two-member teams, each team managing six to eight cases. Lengthy cases may pass through the hands of several student teams over time, Smetanka said. Medical students also rotate through the law clinic to learn more about information they may be called upon to provide during their professional careers.

Clients are often referred by hospital social workers, welfare departments or private attorneys. In Reigh’s case, “She was doing this battle on her own. She was having financial difficulties and she called us,” Smetanka said.

The case was accepted because it appeared it would be difficult for Reigh to find an attorney and afford moving ahead with the process on her own, Smetanka said.

Reigh suffered severe complications from diabetes, but her kidneys were healthy. She qualified as a transplant candidate at UPMC but was denied Medicare coverage for the procedure. Although Reigh’s secondary insurance paid for her 2004 transplant, Pitt’s law clinic continued to challenge the NCD.

In July 2005, Medicare administrators agreed to reconsider the policy.

A proposed decision is due in late January 2006, with completion of the review expected by late April.

Reigh’s appeal is on hold for now, while the NCD is reviewed.

Smetanka and her students who staff the health law clinic are hopeful.

“They must have seen some merit to our argument, or why would they have initiated a review while our case is pending?” Smetanka said.

A conference call with an appeals board judge at the Department of Health and Human Services is set for Jan. 5. Although the NCD is not scheduled to be decided by then, Smetanka said she hopes the call will give a sense of whether to proceed on Reigh’s behalf. The team may choose to go ahead with the appeal in case the organ is rejected and Reigh needs coverage.

Reigh’s successful transplant has cured her diabetes and improved her quality of life by relieving the chronic debilitating complications she suffered.

“The fact that she has her pancreas makes it a lot less worrisome,” Smetanka said.

Reigh, Smetanka and doctors from the Thomas E. Starzl Transplantation Institute are among a number of individuals who submitted written comments urging Medicare to change its policy.

A submission signed by Starzl doctors Ngoc L. Thai, Ron Shapiro and Amadeo Marcos called the surgery “life-saving” for diabetics who have severe complications and cited advancements in pancreas transplants and aftercare that have increased survival rates for patients.

“Most importantly, isolated pancreas transplantation can restore independence and a sense of self-worth to patients with disabling diabetes, allowing them to again become productive members of society,” they stated.

Reigh, who no longer needs insulin, labeled her surgery a success.

“A diabetic who is dying from serious complications due to this disease should not have to wait for end-stage renal failure to receive a pancreas. Some diabetics never get kidney failure, but still die from serious complications that develop from the progression of this disease. It is now known that a solitary pancreas transplant stops this progression. I am the living proof,” she stated.

Diabetes is the fifth leading cause of death in America, according to the American Diabetes Association. Its life-threatening complications include heart disease, blindness, high blood pressure, stroke, kidney disease or circulatory problems leading to amputation. Experts estimate that 20.8 million Americans, about 7 percent of the U.S. population, have diabetes.

Changing the transplant coverage policy isn’t expected to open the floodgates, Smetanka said, because transplants would be limited to those with severe complications or diabetes that is resistant to other treatment.

“Nobody is saying just because you have diabetes that Medicare is going to cover you for a pancreas transplant.” Smetanka said.

—Kimberly K. Barlow