Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Appellate Division
SUBJECT: Wisconsin Department of Social and Health Services
DATE: February 1, 1993
Docket No. A-92-54
Decision No. 1387
DECISION
The Wisconsin Department of Social and Health Services
(Wisconsin)
appealed a determination by the Health Care Financing
Administration
(HCFA) disallowing $529,568 in federal financial participation
(FFP)
claimed by Wisconsin under the Medicaid program during the period
July
1, 1983 through June 30, 1989. HCFA determined that Wisconsin
had
claimed FFP for drug products that were ineligible for
Medicaid
reimbursement because the drug products had been deemed
either
ineffective or "identical, related, or similar" (IRS) to
ineffective
drugs. HCFA disallowed FFP for numerous drug
products, with the
majority of the disallowed FFP being for the drugs
dipyridamole and
Naldecon. 1/
In LTE and IRS Drug Disallowances, DAB No. 1366 (1992), the Board
reviewed
HCFA disallowance determinations received by 14 states. While
the drug
products involved in these appeals varied from state to state,
three drug
products -- dipyridamole, Naldecon, and Bellergal -- were
predominant,
and the Board specifically addressed each of these drugs.
After reviewing DAB No. 1366, Wisconsin withdrew its appeal in this
case
except for those claims arising from dipyridamole and Naldecon
and
agreed to the issuance of a summary decision by the Board to resolve
the
disallowances for those drug products. HCFA also agreed that DAB
No.
1366 should serve as the basis for a summary Board decision with
respect
to dipyridamole and Naldecon.
In DAB No. 1366, we concluded in relevant part as follows:
o We find that dipyridamole is
eligible for retroactive
reimbursement, and we therefore reverse the
disallowances for
that product.
o We find that it was unreasonable
to expect the States to
identify Naldecon and the Naldecon-related
drugs as IRS to
Dimetapp [a drug found to be ineffective], and we
therefore
reverse the disallowances for those drugs. However we
sustain
any disallowance for the period after the issuance of
the
September 1989 State Medicaid Manual, which provided notice
to
the States that Naldecon was IRS. . . . 2/
At 39.
Conclusion
Accordingly, based on the analysis in DAB No. 1366, which we
incorporate
by reference, we reverse the disallowances for dipyridamole
and
Naldecon. Additionally, as we provided for in DAB No. 1366,
if
Wisconsin believes itself adversely affected by HCFA's recalculation
of
the disallowance amount, it may appeal that recalculation
determination
to the Board within 30 days of that determination.
_____________________________
Donald F. Garrett
_____________________________ M.
Terry
Johnson
_____________________________ Norval
D.
(John) Settle Presiding Board
Member
1. For our purposes here, Naldecon also includes other drug
products
that are "Naldecon-related," such as drug products which have
among
their ingredients either more than one decongestant or more than
one
antihistamine.
2. Since the audit period in this appeal was from July 1, 1983
through
June 30, 1989, our affirmation in DAB No. 1366 of disallowances
for
Naldecon after the issuance of the September 1989 State Medicaid
Manual
is not applicable to Wisconsin