WASHINGTON, D.C BEFORE THE OFFICE, ASSISTANT SECRETARY OF DEFENSE (HEALTH AFFAIRS) UNITED STATES DEPARTMENT OF DEFENSE

Transcription

1 ASSISTANT SECRETARY OF DEFENSE WASHINGTON, D.C HEALTH AFFAIRS BEFORE THE OFFICE, ASSISTANT SECRETARY OF DEFENSE (HEALTH AFFAIRS) UNITED STATES DEPARTMENT OF DEFENSE Appeal of Sponsor: SSN : 1 1 OASD (HA) Fle FINAL DECISION 1 Ths s the FINAL DECISION of the Assstant Secretary of Defense (Health Affars) n the CHAMPUS Appeal OASD(HA) Case Fle pursuant to 10 U.S.C and DoD R, chapter X. The appealng party s the CHAMPUS benefcary, the wfe of a retred enlsted member of the Unted States Army. The appeal nvolves clams for physotherapy treatments, corn removal, and routne podatry care for both feet receved from January 23, 1978, through July 21, Clams for routne podatry servces that preceded, as well as servces rendered concurrently wth, the ntal 60-day perod for physcal therapy were orgnally allowed. CHAMPUS dened cost-sharng of all clams for servces receved after June 12, The amount n dspute s $1, n blled charges, ncludng $ n charges that were submtted durng the appeal. The hearng fle of record, the tape of oral testmony and the argument presented at the hearng, the Hearng Offcer's Recommended Decson, and the Analyss and Recommendaton of the Drector, OCHAMPUS, have been revewed. It s the Hearng Offcer's recommendaton that the Frst Level Appeal determnaton by OCEIAMPUS denyng coverage of physcal therapy followng the ntal 60-day perod of therapy be upheld on the bass that the care was not medcally necessary. The Hearng Offcer found that the benefcary had establshed that she had a systemc medcal dsease, Charcot-Mare-Tooth dsease, affectng her lower lmbs whch caused her foot condton; therefore, the Hearng Offcer concluded that the CHlL4PUS excluson of corn removal and routne podatry servces dd not apply. The Hearng Offcer, however, found there was no showng of medcal necessty for the corn removal and routne podatry care or physcal therapy after the end of the ntal 60-day perod of physcal therapy, and recommended denal of CHAMPUS cost-sharng of the clams nvolved. The Drector, OCHAMPUS, does not concur wth the Hearng Offcer's Recommended Decson to deny CHAMPUS cost-sharng of care after the ntal 60-day perod.

2 2 Under Department of Defense Regulaton R, chapter X, the Assstant Secretary of Defense (Health Affars) may adopt or reject the Hearng Offcer's Recommended Decson. In the case of rejecton, a FINAL DECISION may be ssued by the Assstant Secretary of Defense (Health Affars) based on the appeal record. The Assstant Secretary of Defense (Health Affars), after due consderaton of the appeal record, adopts the recommendaton of the Drector, OCHAMPUS, to alow CHAMPUS cost-sharng of all treatment. The FINAL DECISION of the Assstant Secretary of Defense (Health Affars) s, therefore, to allow CHAMPUS cost-sharng of all clams n dspute nvolvng corn removal, routne podatry servces, and physcal therapy. The appealng party s the wfe of a retred enlsted member of the Unted States Army. On July 27, 1979, the benefcary slyned a CIIANPUS clam ana submtted t to the CHAMPUS Fscal Intermedary, Blue Cross of Rhode Island, for care receved from Samuel S. Norway, D.P.M., from January 23, 1978, through June 19, Subsequently, addtonal clams were fled wth the CHAMPUS Fscal Intermedary for care receved from Dr. Norway through September 16, Dr. Norway, the attendng podatrst, descrbed the patent'scondtonnaletterdated January 27, 1981, as follows: "[The benefcary] was born wth a slght club foot deformty. She has metatarsus adductus and osteo arthrts [sc]. "She also develops nflamed plantar corns on her rght andleft foot overlyng tbal sesamods because of her condton." The CHAKPUS clams ndcate frequent offce vsts wth occasonal physcal therapy, consstng of whrlpool and ultrasound treatments, and protectve paddng of the feet. In addton, the benefcary receved several sterod njectons. The followng s an temlzaton of treatments receved and CHAMPUS payments. Abbrevatons used n the temzaton are OV (Offce Vst), W (Whrlpool), and US (Ultrasound) Dates , ov ov ov w, us, ov w, us, ov cortcosterod PI, us, ov ov Clam $ STjjB

3 J Dates Servces Clam v-Etnflammaton medcaton) ov ov ov w, us, ov w, us, ov w, us, ov w, us, ov w, us, ov 19. GO w, us, ov W, US, OV Cortcosterod 1 w, us, ov w, us, ov Soft orthotc to correct foot posture and releve pressure K, us, ov 2 w, us, ov 2 P, us, ov 2 w, us ov 2 w, us, ov 2 P7, us, ov 2 13.OO 4.00 ljot processed 0.0g Total --I $9 of the $45 allowed Gn the clams, the CHAl4PUS Fscal Intermedary pad $ as the CfIAMPUS cost-share after deductng $65.00 for deductbles fcr fscal years 1978 and 1979 and $96.25 as the patent's cost-share.

4 I Although 4 the CHAMPUS Fscal Intermedary cost-shared the offce vsts from January 23, 1978, through October 5, 1979, physcal therapy (whrlpool and ultrasound treatments) was cost-shared only for the ntal 60-day perod (Aprl 14, 1978, through June 12, 1978) of physcal therapy. All other physcal therapy sessons were dsallowed as exceedng the general lmtaton n the CHAMPUS regulaton for coverage of outpatent physcal therapy;.e., up to 60-days of physcal therapy unless the attendng physcan car, document the medcal necessty and reasonably antcpated results of extended. therapy. The benefcary appealed the fscal ntermedary's decsons partally denyng her clams. Durng revew of ths appeal, Dr. Norway provded the followng nformaton regardng the necessty for physcal therapy: "Patent has metatarsus adductus. Ths causes nflamed corns to occur plantar to tbal sesamod [sc]. "These are removed perodcally & padded to keep pressure off of enlarged tbal sesamods. "Ultrasound s used to releve swellng & edema of patent plantar to corns [sc]. "Patent s [then] able ror a perod of tme. 'I to walk comfortably Folowng revew of the medcal documentaton submtted by Dr. Norway, the medcal advsory staff of the fscal ntermedary supported the denal of extended physcal therapy. The benefcary's appeal was dened by the fscal ntermedary both at the nformal revew level and at the reconsderaton level. In support of the benefcary's appeal to OCHAMPUS, Dr. Norway submtted a letter dated July 25, 1981, contanng the followng: "Dagnoss: Pes Cavus. Metatarsus adductus rght and left foot wth hammerng of 2, 3, 4, 5 toes. Patent develops severely nflammed [sc] nucleated corns plantar 1 and 5 Netatarso-Phalangeal artculatons. Patent has been njected ntra esonally wth cortco sterods. "Treatment: Removal of corns, whrlpool, ultra sound to releve nflammaton of lesons and pan of tbal sesamods. Patent s

5 5 * * * wearng an applance to releve pressure and also wears pads of felt after treatment. "Ths patent walks better after an offce vlst wth physo-therapyand s able to ambulate wthout pan. "Ths s not a matter of physo-therapy alone but complete treatment whch s necessary to patent's feet and well beng." Dr. Norway's letter also enclosed a CHAHPUS clam for addtonaltreatment sessons not prevouslyfled wth the CHAMPUS Fscal Intermedary. These sessons occurred on January 22, February 16, March 20, Aprl 28, May 19, June 15, and July 21, 1981.Each sesson nvolved the removal of corns, ultrasound treatment, and the applcaton of protectve paddng. The blled charge for each sesson was $25.00, for a total charge of $ Because the treatment was the same type of care and part or the same epsode of care, the addtonal clam has been consoldated n the benefcary's appeal. OCHAr4PUS requested a medcal revew of the clams by the Colorado Founuaton for Medcal Care. The two revewers, one a specalst n nternal medcne and one a specalst n pcjdatrc medcne, opned that the physcal therapy was an acceptable mode of therapy for the patent's condton of "tbal sesamodts wth assocated capsults of the 1st NP artculaton. I' The revewers further opned that: "Physcal therapy may be of some value to a patent wth ths condton, but generally t would only be of short term value. To be effectve, therapy would ordnarly be admnstered 2 to 3 tmes per week for 2 or 3 weeks. Gvng nternttent therapy over an extended perod of tme s not consdered effectve therapy. I' The OCHAMPUS Frst Level Appeal determnaton noted that benefts for physcal therapy beyond the 60-d~y perod were dened by the fscal ntermedary on the bass that the medcal necessty for such care had not been establshed. Eased upon a revew of the medcal evdence and clams hstory, the Frst Level Appeal upheld the denal by the fscal ntermedary. The benefcary then requested a hearng, whch was held on September 22, 1982, n Newark, New Jersey, before OCIIAMPus Hearng Offcer, Mr. Edward Fnkelsten. Pror to the hearng, OCEIAMPUS placed n ssue the partal payment of the benefcary's clams as beng erroneous due to the Regulaton's excluson of coverage of corn removal and other

6 6 -~ routne podatry servces. At the hearng, the appealng party argued that the care vas not routne based on a letter from her new treatng podatrst, Harold S. Estersohn, D.P.M. Dr. Estersohn's letter dated September 21, 1982, states: "Ths s a 46 year old female complanng of pan underneath the 1st metatarsal b-lateral, rght worse than left. "Past medcal hstory conssted of gong to a podatrst snce she was 16 years old. She had cardac b-pass [sc] surgery done December 28, 1981, and was dagnosed as Charcot Mare Tooth Dsease by Dr. Chow, M.D. "Examnaton reveals md-equnus type foot wth plantar flexed 1st metatarsal b-lateral and underlyng ntractable plantar keratoss. She has met=adductus [sc] wth contracted lesser toes and hallux abductus [sc] b-lateral. Xrays confrmed the dagnoss of md-foot equnus wth plantar flexed 1st metatarsal b-lateral. "In my opnon ths patent had a neurologcal osseous foot condton due to Charcot Mare Tooth Dsease whch created the plantar flexed 1st metatarsal and underlyng plantar keratoss creatng panful a syndrome. Snce she had b-pass [sc] surgery recently, surgcal correcton of ths condton s not feasble. Conservatve therapy has been attempted to gve her some relef of ths pan from her foot problem." The Hearng Offcer has ssued hs Reconmended Decson and all pror levels of admnstratve revew have been exhausted. Issuance of a FINAL DECISION s, therefore, proper. The prmary ssues n dspute are (a) whether the corn removal and routne podatry care receved durng offce vsts from January 23, 1978, through July 21, 1981, are specfcally excluded from CHAMPUS coverage by the Regulaton: and (b) whether physca therapy provded after 60 days was medcally necessary. - In general, podatrsts are recognzed as authorzed, ndvdual provders of care under CHAMPUS. The CHAMPUS regulaton, DoD R, chapter VI, C.3.c.(3), authorzes payment, on a fee-for-servces bass, of servces of a Doctor of Podatry Medcne provded such servces are otherwse authorzed CIIAMPUS benefts.

7 7 Benefts avalableunder the CHAMPUS Basc Program are descrbed n DoD R, chapter IV, A.1., as follows: I-- "ScoQe of Benefts. Subject to any and all applcable defntons, condtons, lmtatons, and/or exclusons specfed or enumerated n ths Regulaton, the CHAMPUS Basc Program wll pay for medcally necessary servces and supples requred n the dagnoss and treatment of llness or njury....'i "... the level of servces and supples (that s, frequency, extent, and knds) adequate for the dagnoss and treatment of llness or njury,... Medcally necessary ncludes concept of approprate medcal care. I' Approprate medcal care s uefned n DoD k, chapter 11, B.14., n part, as: "That medcal care where the medcal servces performed n the treatment of a dsease or njury,... are n keepng wth the generally acceptable norm for medcal practce n the Unted States. I' Fnally, as concerns podatry servces, DoD R, chapter IV, G.31., specfcally excludes from CEIMIPUS coverage: "Removal of corns or calluses or trmmng of toenals, and other routne podatry servces, except those requred as a result of a systemc medcal dsease affectng the lower lmbs, such as severe dabetes." The Hearng Offcer summarzed the benefcary's condton and treatment as follows: "[The benefcary] who was born wth a slsht club foot deformty, receved physcal therapy treatment from Samuel S. Norway, D.P.H., from January 23, 1578, through September 16, 1980, for metatarsus adductus, sesamodts and osteoarthrts n her rght and left feet.... The benefcary developed nflamed plantar corns on her rght and left feet overlyng tbal sesamods because of her condton. Treatments were usually b-weekly, consstng of whrlpool, ultrasound, removal of corns, protectve

8 8 paddng of feet and sterod njectons (fve tmes from January, 1978, through December, 1979)." The Hearng Offcer found that the benefcary was dagnosed as havng Charcot-Mare-Tooth dsease, a systemc medcal dsease, whchcausedherfoot condton and, n turn, the development of corns on her feet. Therefore, he found that the benefcary's foot care was not Eer se excluded from CHAMPUS coverage as routne podatry care. I concur and adopt the Nearng Offcer's fndngs. The CHAMPUS regulaton, DoD R, chapter IV, (2.3. j., specfcally addresses coverage of physcal therapy, n part, as follows: I'TO be covered, physcaltherapymustbe related to a covered medcal condton. If performedby other thana physcan, the benefcary/patent must be referred by a physcan and the physcal therapy rendered under the supervson of a physcan. '' (1) Outpatent physcal therapy s generally lmted to a sxty (60) day perod, two (2) physcal therapy sessons per week, n connecton wth each medcal condton. In order for CHAMPUS benefts to be extended for physcal therapy rendered for a longer perod of tme than sxty (60) days, and/or for nore than two (2) sessons per week, requres submsson by the attendng physcan of documentaton as to medcal necessty and the reasonably antcpated results of such therapy.'' Dr. Norway provded physcal therapy (.e, whrlpool and ultrasound treatments) begnnng on Aprl 14, 1978, ar,d contnung ntermttently through July 21, On the 54 dates of care blled by Dr. Norway, 34 sessons of physcal therapy were ncluded. "Treatment: Removal of corns, whrlpool, ultra sound to releve nflammaton of lesons and pan of tbal sesamods. Patent s l- 1 c f j

9 ..- * * * wearng an applance to releve pressure and also wears pads of felt after treatment. "Ths patent walks better after an offce vst wth physo-therapyand s able to ambulate wthout pan. "Ths s not a matter of physo-therapy alone but complete treatment whch s necessary to patent's feet and well beng." The Hearng Offcer found that physcal therapy provded by Dr. Norway followng the ntal 60-day perod was not medcally necessary as requred by the CHAMPUS regulaton. I dsagree wth the Hearng Offcer and reject hs fndng. Although t s dffcult to determne the medcal necessty or approprateness of Dr. Norway's servces from the lmted nformaton he provded, I fnd the nformaton from Dr. Estersohn and the testmony at the hearng establsh the medcal necessty or the dsputed care. The record supports fndngs wth respect to a systemc dsease, chroncty or the condton, and the need for long term therapy of the general type the benefcary has been recevng. Based on hs fndng that Dr. Norway's treatment plan followng the ntal 60-day perod was not medcally necessary, the Eearng Offcer also recommended denal of CHAIWUS coverage of all servces, ncludng podatrc servces, receved after June 12, Consstent wth my fndng that the physcal therapy beyond 60 days was medcally necessary, I reject the Hearng Offcer's recommendaton to deny CHAMPUS coverage of corn removal and other podatrc servces receved after June 12, In summary, t s the FINAL DECISION of the Assstant Secretary of Defense (Health Affars) that the appealng party's CHAMPUS clams for physcal therapy and podatrc servces receved from January 23, 1978, and July 21, 1981, may be cost-shared. The benefcary's appeal s allowed. Wllam M*er,