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February 2, 2006

Law clinic work could change Medicare rule

Medicare administrators are proposing a change in policy that would relax restrictions on which pancreas transplants are covered for diabetic patients who need them.

The proposed decision memorandum released Jan. 26 by the Centers for Medicare and Medicaid Services (CMS), the group that sets coverage policy, is being viewed as a victory at the Pitt Health Law Clinic. The clinic’s work on behalf of a UPMC patient who was denied coverage for a transplant sparked a review of the policy established before advances in anti-rejection medications that have made the surgery much more successful.

Under the existing 1995 National Coverage Decision (NCD,) Medicare covers pancreas transplants for diabetes patients only in conjunction with or after a kidney transplant.

Now, in the culmination of a review begun in July 2005, CMS is proposing that pancreas transplants be covered as well for some Medicare beneficiaries who have diabetes that cannot be controlled by other treatments and who are otherwise fit candidates for a transplant. The proposed guidelines are in line with American Diabetes Association recommendations, said associate law professor Stella Smetanka, who supervises the Health Law Clinic.

CMS is accepting additional comments regarding its proposal through Feb. 26. The coverage analysis process is scheduled to wrap up by late April. (To comment or view a timeline, visit on line.)

The Health Law Clinic sparked the proposed changes by challenging the NCD on behalf of Sharon Reigh of State College. Reigh suffered severe complications from diabetes, but had healthy kidneys. Although she qualified as a transplant candidate at UPMC, she was denied Medicare coverage for the procedure. Secondary insurance paid for Reigh’s transplant in 2004, but the law clinic has continued to challenge the NCD to ensure Reigh would be covered should an additional transplant be necessary.

Smetanka has been unable to reach Reigh since the proposed decision was released, but said she has received excited responses from former students who worked on the case during their time with the Health Law Clinic.

She is encouraged by the recommended changes to Medicare coverage. “I don’t anticipate any barriers to getting this passed,” she said.

Smetanka said she is thankful that Reigh got the transplant she needed without having to wait for the CMS decision.

“It’s a long time coming, but that’s the way things are,” Smetanka said. “She would be dead by now, she’d have had to wait so long. Fortunately the second insurer made an exception to cover her….It really encouraged Sharon that she’s the one instrumental in paving the way to make it less onerous for others.”

—Kimberly K. Barlow

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