Caldera v. The Ins. Co. of the State of PA

This case involved the interplay between the Medicare Secondary Payer Statute (MSP), 42 U.S.C. 1395y(b), and Texas workers' compensation law. At issue was whether the MSP preempted a state law that required a workers' compensation claimant to obtain preauthorization from the relevant carrier before incurring certain medical expenses. The court held that it did not. The court concluded that Congress intended the MSP to complement, no supplant, state workers' compensation rules. This included the preauthorization requirement that plaintiff failed to meet before he filed suit. The court rejected plaintiff's claim that Medicare's conditional payment for his surgeries - which equated to a determination that his surgeries were medically unnecessary - rendered the state-law preauthorization requirement "moot" because preauthorization likewise depended on a showing of medical necessity. Accordingly, the court affirmed the district court's dismissal of plaintiff's claim for failure to state a claim under Rule 12(b)(6). View "Caldera v. The Ins. Co. of the State of PA" on Justia Law