Medicare Answers: What Does Medicare Cover When Dealing With Lyme's Disease?

  • Originally published August 16, 2013 , last updated December 23, 2014
  • Medicare
Medicare Answers: What Does Medicare Cover When Dealing With Lyme's Disease?

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This week’s questions deal with a client who suffers from Lyme’s disease and determining what is covered by Medicare.

Paul asks,

I have a prospective client who will be 65 in a couple months. She has been on Social Security, disabled and on Medicare A & B for many years . The nature of this prospective client’s disability is Lyme’s disease (from ticks). This person requires in-home IV infusion therapy that was not developed for Lyme’s disease. Her providers have been submitting the bills for her durable medical equipment (DME - infusion tubing, etc.) and drugs to Medicare. Medicare has been declining to pay because the IV drug is covered under Part D, but she doesn’t have Part D, and Medicare doesn’t cover the infusion tubes under Part B, because Medicare says the diagnosis of Lyme’s disease does not necessitate the DME that she has been receiving. So the providers then submit the claim to the group plan, and the group plan then pays for the DME and infusion drugs.

I have referred her to the manufacturers of the DME and the drugs for financial help, but both entities say they will not provide financial help because she is Medicare-eligible. Other than going through an appeal process with Medicare, do you have any other recommendations?

Dear Paul,

I have to applaud your research efforts for your client. You have covered all of the bases for sure. Often times I cannot top the agent’s research. The only thing I could add is where the infusion is given might affect coverage. Instead of at home, maybe have the infusions done in the doctor’s office or a hospital. You might try her doctor’s claims submission person as they are experts on what Medicare covers or and what they do not cover. As you stated Medicare denies coverage as it is covered under Part D. This would suggest you should immediately sign her up when eligible for Part D. Because she is losing group coverage or eligible coverage, she should not have to pay a penalty. Do your research to see how each plan pays for the drugs. Because she is now turning 65 she has a new open enrollment period to choose a plan for any carrier.

It is a sad situation and the government plans are not going to provide coverage on all items. I certainly have your client in my prayers, as it sounds like her health is not a very easy situation to be in.