Maximum Comfort vs. CMS
It doesn't look like the industry is any closer to answering this question: Does a CMN, in and of itself, establish medical necessity?
The U.S. Court of Appeals for the Ninth Circuit sided with CMS Dec. 21, saying the agency has the right to require documentation beyond CMNs for power wheelchairs ( Click here to download to the decision). It's the latest chapter in Maximum Comfortâ€™s attempts to prove that CMS wrongly demanded it repay about $600,000 for failing to supply documentation beyond CMNs to establish medical necessity for certain claims.
Since the late 1990s, the case has worked its way through the judicial system: Cignaâ€™s in-house administrative process (Maximum Comfort lost), two administrative law judges (won), the Medicare Appeals Council (lost) and the U.S. District Court for the Eastern District of California (won). CMS appealed the district court decision, sending the case to the Ninth Circuit.
In its opinion, the Ninth Circuit referred to the Medicare Act subsection on CMNs, stating, â€œThe subsection does not state that the certificate of medical necessity is the sole vehicle for claims reimbursement, nor does it state that a completed certificate established, by itself, a right to reimbursement.â€
With the score even, at 2-2, CMS and Maximum Comfort have one more round to go: the U.S. Supreme Court.