TN 1 (07-04)

TO REQUEST THIS NOTICE:

If fill-in A is required, enter on SSA-5002: “Send notice 1076A.”

If fill-in AB is required, enter on SSA-5002: “Send notice 1076B with 2 inserts        and         .”

If fill-in C is required, enter on SSA-5002: “Send notice 1076C.”

If instruction D applies, determine applicable paragraph(s) for insert and enter on SSA-5002: "Send notice 1076D with the following insert    (enter paragraphs)   .”

If fill-in E is required, enter on SSA-5002: “Send notice 1076E.”

This refers to your claim for entitlement to Medicare benefits on the basis of a kidney condition. The law provides Medicare coverage if it has been medically determined that a course of dialysis or a kidney transplant is the required treatment and the individual is undergoing regular dialysis or has received a kidney transplantation. In addition, to be entitled, the individual must either meet certain insured status (work) requirements under applicable provisions of the Social Security or Railroad Retirement Acts or be entitled to a monthly social security benefit or railroad annuity (or be the spouse or dependent child of a person who meets such insured status requirements or who is entitled to a monthly benefit).

You are not entitled to Medicare coverage under these provisions because (use fill-in A, A-B, E, or C (if a transplant or dialysis is not involved), or follow instruction D.).

1. You do not meet the insured status (work) requirements under applicable provisions of the Social Security or Railroad Retirement Acts and are not entitled to monthly social security or railroad benefits. (Add (B)—if filing as spouse or dependent child).

2. Your (spouse) (parents) also (do/does) not meet these requirements.

3. The evidence in your case shows that you are not receiving a regular course of dialysis treatment nor have you received a kidney transplant.

4. If relationship or dependency requirements are not met, the applicable paragraphs in NL 00708.100 should be used with appropriate modification.

5. Under the law, you are responsible for furnishing evidence to support your claim. Although we requested additional evidence, you have not given it to us. Therefore, our determination is based on the evidence in your file. This evidence does not show that you meet the requirements for Medicare coverage based on chronic renal disease.

If you believe this determination is not correct, you may request that your case be reexamined. If you want this reconsideration, you must request it not later than 60 days from the date you receive this notice. You may make your request through any Social Security office. If additional evidence is available, you should submit it with your request.

Enclosure: HCFA-10128