Cases which require review of unclear or irreconcilable conflicts in the medical information
(i.e., neither clearcut affirmations nor reversals of medical denials or cessations)
will be forwarded via SSA-559 to CMS, BPP, OEP, DMEP, Medicare Entitlement Branch,
Room 349 East High Rise without development. On the transmittal, show “ESRD Reconsideration Claim.” Cite the issue and/or evidence which makes the case other than a clearcut denial
or cessation or other than a clearcut reversal of such. Place a self-addressed SSA-559
under the SSA-559 to CMS. On the second SSA-559, indicate that the folder should be
returned to your office. An acknowledgement of receipt of the reconsideration request
must be sent to the requester for cases referred to CMS. If the requester is a third
party, send a copy of the acknowledgement letter to the claimant or beneficiary. Send
cases to CMS via OD, SPB, 3-M-25 Operations Building.
After review, CMS may on its own secure medical clarification or return the claim
and indicate what, if any, additional medical development is needed. CMS will also
indicate the proper course of action and necessary language for the notification to
the claimant.