April 30, 2008
Kelley Drye successfully represented, pro bono, a financially disadvantaged Tennessee farmer, in a Medicare Part D appeal.
Unlike the original version of Medicare, Part D provides outpatient drug coverage exclusively through private health insurance plans that contract with Medicare. However, these private plans must comply with federal Medicare regulations.
All administrative complaints must first adhere to a private plan's internal appeals process before reaching external administrative or judicial review.
The client's private health insurance company had repeatedly denied his request for Januvia, a diabetes medicine, even though alternate treatments caused the client to suffer from several bouts of congestive heart failure.
Kelley Drye collected documents from the client and the client's doctor, including denial notices from the insurance company and a letter stating that Januvia was medically necessary. Medicare regulations permit insurance
companies to develop formularies listing preferred drugs. However, they must approve drugs not listed on their formularies when other treatments would not be as effective as a prescribed drug or would cause adverse effects.
Kelley Drye filed an appeal with the insurance company on April 7, 2008. When the insurance company denied this appeal, Kelley Drye filed a request for an expedited appeal on April 11, 2008 with the independent review agency,
Maximus Federal Services ("Maximus"), in accordance with Medicare regulations. In the appeal, Kelley Drye argued that the client's insurance company should provide coverage of Januvia because the other recommended drugs caused severe
adverse effects, including the client's being rushed to the hospital on five separate occasions with episodes of congestive heart failure. Moreover, the client had shown positive results when treated with samples of Januvia provided by
his doctor. This appeal proved successful, and Maximus sent a letter on April 14, 2008 to the insurance company and to Kelley Drye ordering the insurance company to provide coverage for Januvia. The client is now receiving the medicine
that he needs. The Medicare Rights Center, a national non-profit organization that assists people with various Medicare
issues, referred this case to Kelley Drye.
Partner Robert E. Crotty supervised the case.