12-000513 Nicole Demott Vugteveen vs. Department Of Management Services, Division Of State Group Insurance Status: Closed Recommended Order on Wednesday, September 26, 2012.

Summary: Reimbursement cannot be approved for device that is experimental or investigative. Miscoding caused delay in the denial of the claim.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

NICOLE DEMOTT VUGTEVEEN , )

)

Petitioner , )

)

vs. ) Ca se No. 12 - 0513

)

DEPARTMENT OF MANAGEMENT )

SERVICES, DIVISION OF STATE )

GROUP INSURANCE , )

)

Respondent . )

)

RECOMMENDED ORDER

Pursuant to notice , a formal hearing was held in this case

on September 4, 2012, in Viera, Florida, before J.D. Parrish, a

designated Administrative Law Judge of the Division of

Administrative Hearings.

APPEARANCES

For Petitioner: Nicole Vugteveen , pro se

700 North Atlantic Avenue, No. 112

Cocoa Beach, Florida 32931

For Respondent: Sonja P. Mathews

Department of Management Services

4050 Esplanade Way, Suite 160

Tallahassee, Florida 32399 - 0950

STATEMENT OF THE ISSUE

Whether Petitioner, Nicole Demott Vugteveen (Petitioner),

is entitled to reimbursement for a medical device that

Respondent, Department of Management Services, Division of State

Group Insurance (Department or Respondent) , maintains is not

covered under the State of Florida PPO self - insured medical

plan.

PRELIMINARY STATEMENT

On October 12, 2011, Respondent issued a letter advising

Petitioner that a medical device known in this record as a

Bioness L300 is not covered und er the state ' s medical plan and

that reimbursement for the purchase of the device would not be

made. Petitioner promptly challenged that decision. The case

was referred to the Division of Administrative Hearings (DOAH)

for formal proceedings on February 7, 2012. Although initially

set for hearing for April 17, 2012, the case was continued on

three occasions to accommodate the parties.

At the hearing on September 4, 2012, Petitioner testified

on her own behalf and presented the testimony of Michelle

Dem ott. Petitioner ' s Composite Exhibit 1 was admitted in to

evidence. Respondent presented the testimony of Kellette

Register, Kathy Flippo, Daniel Hudec, Mark A. Phelps, and

Georgianne Grant. Respondent ' s Exhibits 1, 10, 11, 12, 13,

and 26 were admitted in to evidence. A transcript of the

proceeding was not filed.

Respondent ' s Proposed Recommended Order was filed on

September 18, 2012. It has been considered in the preparation

of this Recommended O rder. Petitioner did not file a proposed

order.

FINDIN GS OF FACT

1. At all times material to this case Petitioner was a

participant in the State of Florida ' s Group Health Insurance

Plan. This plan is managed by Florida Blue , formerly known as

Blue Cross and Blue Shield of Florida. The plan is administered

by Respondent. It is Respondent ' s duty to oversee the

administration of the plan and to assure that it complies with

all applicable regulatory and medical guidelines.

2. As a participant of the plan, Petitioner was entitled

to the benefits of the plan. Accordingly, medical services and

certain durable medical equipment covered by the plan are

reimbursable.

3. Typically, individuals or companies who provide medical

services or products for participants ' illnesses are known as

" providers. " These provid ers may seek payment or reimbursement

for their efforts , either directly from the insurance plan or

from the patient to whom services are rendered. In the case of

the latter situation, the patient is required to file the claim

form for reimbursement from the plan.

4. At all times material to this case, a company known as

Mid - Florida Prosthetics and Orthotics (Mid - Florida) was a

provider of medical devices. Mid - Florida files medical claims

for its patients when the devices provided are covered by

insura nce but will not file claims for devices that are not.

After doing extensive research into products offered by Mid -

Florida, Petitioner approached the company with the notion of

purchasing a device to assist her condition.

5. Petitioner ' s long - term medica l history has resulted in

a profound weakness on one side of her body. Gait and

ambulatory issues have impaired progress in recovery.

Petitioner sought to purchase a medical device from Mid - Florida

in order to provide stimulation to her muscles on the we ak side.

It is undisputed that Petitioner met all medical prerequisites

for the purchase of the device. Petitioner was allowed to test

the device to verify it would help.

6. At the time of the purchase, Mid - Florida knew the

device was not covered by Pet itioner ' s insurance. Mid - Florida

did not file for payment from Petitioner ' s insurance plan.

Instead, Petitioner purchased the device from Mid - Florida and

file d for reimbursement. Although Petitioner knew Mid - Florida

would not file the claim, it is dispu ted whether Petitioner knew

or should have known that the device would not be covered by

insurance.

7. At the heart of this dispute , is the device itself: a

Bioness L300. This device is a neuromuscular stimulator that

sends impulses to the area where i t is attached (in this case

the leg) to improve mobility. Petitioner maintains and

Respondent does not dispute whether the device has been

medically helpful.

8. At all times material to the allegations of this case,

however, the state ' s insurance plan did not cover the Bioness

L300. The Bioness L300 is considered an experimental or

investigative product by the insurance plan.

9. Petitioner maintains that , if that were true, the claim

should have been denied and that requests for additional

informati on should not have been issued. Petitioner argues that

it took an inordinate amount of time for the claim to be

processed and then denied , if all along it could not be

approved.

10. To review this matter, the claims process must be

described. In this (a nd all claims) a form is used to process

claims for payment or reimbursement. That form describes the

patient ' s medical condition and the types and amounts of

services or the device intended to treat the medical condition.

Whether or not the claim can be approved is governed by

guidelines established by the insurance plan. The guidelines

include claim codes that are assigned to each type of condition

and service that might be rendered. For a given medical

condition, treatment may be appropriate but the type of

treatment requested may not be approved.

11. In this case, had Petitioner ' s claim been correctly

coded from the beginning, it would have been denied. Instead,

Petitioner ' s claim had incorrect codes that required further

explanation. In simpli stic terms, Petitioner has a medical

condition that warrants medical care, but the device she b ought,

the Bioness L300, is not an approved, reimbursable device for

that care. Under the guidelines that govern this matter, the

Bioness L300 is described as a functional neuromuscular

stimulation that is experimental and investigational for all

diagnosis codes.

12. The state health insurance plan does not cover

devices that are deemed experimental and investigational.

13. Had the forms been correctly coded, Petitioner ' s claim

for reimbursement would have been disallowed or denied at the

time of its submission. The delay in resolving the claim

resulted from the confusion and miscoding of the claim form.

14. The request for additional information regarding the

claim does not constitute an approval of the claim.

CONCLUSIONS OF LAW

15. DOAH has jurisdiction over the parties to and the

subject matter of these proceedings. §§ 120.569 and 120.57(1),

Fla. Stat. (2012).

16. Petitioner bears the burden of proof in this cause to

establish by a preponderance of the evidence that Respondent

should have reimbursed the cost for the purchase of the Bioness

L300.

17. The preponderance of the evidence standard requires

proof by the greater weight of the evidence, or ev idence that

" more likely than not " tends to prove a certain proposition.

See Gross v. Lyons , 763 So. 2d 276 (Fla. 2000).

18. In this case, Petitioner has failed to meet that

burden. Respondent has articulated a complete explanation

regarding why Petitio ner ' s claim was denied. Petitioner has not

presented any evidence to support the approval of the claim. It

is undisputed the Bioness L300 is a functional neuromuscular

stimulation device. The plan that governs payment for medical

devices does not cover the Bioness L300.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of

Law, it is RECOMMENDED that the Department of Management

Services, Division of State Group Insurance, enter a final order

denying Petitioner ' s request for reimbur sement for the Bioness

L300 , as it is not covered by the plan guidelines.

DONE AND ENT ERED this 2 6 th day of September , 2012 , in

Tallahassee, Leon County, Florida.

S

J. D. PARRISH

Administrative Law Judge

Division of Admi nistrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 26 th day of September , 2012 .

COPIES FURNISHED :

Nicole Vugteveen

700 North Atlantic Avenue, No. 112

Cocoa Beach, Florida 32931

Sonja P. Mathews, Esquire

Department of Management Services

Office of the General Counsel

4050 Esplanade Way, Suite 160

Tallahassee, Florida 32399

Jaso n Dimitris, General Counsel

Department of Management Services

4050 Esplanade Way, Suite 160

Tallahassee, Florida 32399 - 0950

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of thi s Recommended Order. Any exceptions

to this Recommended Order should be filed with the agency that

will issue the Final Order in this case.