State Hearing Decision - Hearing Decisions

OHIO DEPARTMENT OF JOB AND FAMILY SERVICES
BUREAU OF STATE HEARINGS
In the matter of:
ISSUE SECTION
JFS 04005 (Rev. 6/2002)
Case Number: County:
5068805786 FRANKLIN
Appeal: Program: Disposition:
1754372
MED
OVERRULED
No Compliance Required
Decision Date:
Request Date:
Hearing Officer:
State Hearing Decision
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02/21/2012
01/19/2012
BRIAN HORST
The Appellant’s mother requested this state hearing to express disagreement with CareStar’s
01/04/2012 notice to deny an increase in skilled nursing services: sixteen hours a day to twenty
hours a day. Based on the testimony, evidence, and applicable policies, the hearing officer
recommended that appeal 1754372 (Medicaid) should be overruled.
FINDINGS OF FACT
1. The assistance group contains the Appellant. She is seventeen years old and in receipt of a
transitions MRDD waiver.
2. The Appellant has diagnoses of (but not limited to): dwarfism; paraplegia; osteoporosis;
scoliosis; tracheal laryngeal malasia; chrondrodystrophy.
3. The Appellant is dependent with all activities of daily living and instrumental activities of
daily living.
4. The Appellant’s current all services plan (ASP) allows for 16 hours a day of skilled
nursing services. These 16 hours may be used through three skilled nursing visits.
5. On an unknown date the mother requested to increase skilled nursing services to 20 hours a
day. The reason for this request was because the Appellant’s father passed away on or about
01/04/2012, the mother needs time to complete errands, and the mother needs rest.
6. On 01/04/2012 CareStar mailed the Appellant notice to deny the request to increase daily
skilled nursing services.
CONCLUSIONS OF POLICY
Policy
Ohio Admin. Code § 5101:3-1-01(A)(2006) Medicaid: Medical Necessity. "Medical necessity"
is a fundamental concept underlying the Medicaid program. Physicians, dentists, and limited
practitioners render, authorize, or prescribe medical services within the scope of their licensure
and based on their professional judgment regarding medical services needed by an individual.
Medically necessary services are defined as services that are necessary for the diagnosis or

STATE HEARING DECISION CONTINUATION
treatment of disease, illness, or injury and without which the patient can be expected to suffer
prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or
part, or significant pain and discomfort. A medically necessary service must: (1) Meet generally
accepted standards of medical practice; (2) Be appropriate to the illness or injury for which it is
performed as to type of service and expected outcome; (3) Be appropriate to the intensity of
service and level of setting; (4) Provide unique, essential, and appropriate information when used
for diagnostic purposes; (5) Be the lowest cost alternative that effectively addresses and treats the
medical problem; and (6) Meet general principles regarding reimbursement for Medicaid
covered services found in rule 5101:3-1-02 of the Administrative Code.
Analysis
The hearing officer found the denial to increase skilled nursing services was correct. There has
not been documented change in the Appellant’s need for care and the Appellant’s medical
impairments are stable; therefore, an increase in skilled nursing services is not medical
necessary.
The mother’s explanation that the father, who passed away, took care of some of the errands and
chores is not enough to meet medical necessity for increased skilled nursing services. The
hearing officer found that the Appellant could have family or friends complete the miscellaneous
errands/chores that do not require medical skills (i.e. filling prescriptions, putting gasoline in
vehicle, grocery shopping, etc.). In addition, the hearing officer found that mother could obtain
home health aide services for assistance with errands/chores.
Finally, the hearing officer found the mother’s testimony, that the Appellant will not require
nursing home admittance if the skilled nursing services are not increased, supported the lack of
medical necessity.
HEARING OFFICER'S RECOMMENDATION
Based upon the testimony, evidence, and applicable policy, the hearing officer recommends that
appeal 1754372 (Medicaid) should be overruled.
FINAL ADMINISTRATIVE DECISION AND ORDER
I found the Hearing Officer's recommendation to be supported by policy and the evidence. Thus,
I hereby adopt the recommendation and appeal 1754372 is overruled.
Hearing Authority
February 21, 2012
Notice to Appellant
This is the official report of your hearing and is to inform you of the decision and order in your case. All papers and materials
introduced at the hearing or otherwise filed in the proceeding make up the hearing record. The hearing record will be maintained
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STATE HEARING DECISION CONTINUATION
by the Ohio Department of Job and Family Services. If you would like a copy of the official record, please telephone the hearing
supervisor at the COLUMBUS District hearing section at 1-866-635-3748.
If you believe this state hearing decision is wrong, you may request an administrative appeal by writing to: Ohio Department of
Job and Family Services, Bureau of State Hearings, P.O.BOX 182825, Columbus, OH 43218-2825 or fax: (614) 728-9574.
Your request should include a copy of this hearing decision and an explanation of why you think it is wrong. Your written
request must be received by the Bureau of State Hearings within 15 calendar days from the date this decision is issued. (If the
15th day falls on a weekend or holiday, this deadline is extended to the next work day.) During the 15-day administrative appeal
period you may request a free copy of the tape recording of the hearing by contacting the district hearings section.
If you want information on free legal services but don't know the number of your local legal aid office, you can call the Ohio
State Legal Services Association, toll free, at 1-800-589-5888, for the local number.
Aviso a la Apelante
Esta es la decisión estatal administrativa de su caso. Todos los documentos y materiales presentados como prueba en la vista o de
otra manera radicados componen el récord administrativo. El récord administrativo será mantenido por el Ohio Department of
Job and Family Services.
Si usted cree que esta decisión estatal administrativa es erronea, usted puede solicitar una apelación administrativa escribiendo al:
Ohio Department of Job and Family Services, Bureau of State Hearings, P.O. Box 182825, Columbus, Ohio 43218-2825 o
facsímil (614) 728-9574. Su solicitud debe indicar por qué usted piensa que la decisión administrativa es erronea. Usted puede
completar la solicitud de apelación incluida con esta decisión. Su solicitud escrita o formulario de apelación tiene que ser
recibido por el Bureau of State Hearings dentro de los 15 días calendario desde la fecha en que esta decisión es expedida. (Si el
15to. día recae sobre un fin de semana o un día feriado, esta fecha límite es extendida al próximo día laborable). Durante el
período de 15 días de apelación administrativa, usted o su representante pueden solicitar una copia gratuita del récord
administrativo y de la grabación de la vista llamando al Bureau of State Hearings al 1-866-635-3748 (seleccione la opción 1 del
menú principal).
Si usted quiere información sobre servicios legales gratuitos pero no sabe el número de su oficina local de servicios legales, usted
puede llamar al Ohio State Legal Services Association, gratuitamente, al 1-800-589-5888, para el número local.
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STATE HEARING DECISION CONTINUATION
Appendix
CareStar’s Exhibits:
Exhibit A – Denial Notice (three pages)
Exhibit B – State Hearing Scheduling Notice (one page)
Exhibit C – Narrative (four pages)
Exhibit D – All Service Plan (eight pages)
Exhibit E – Assessment (thirty nine pages)
Exhibit F – Case Information (four pages)
Exhibit G – Communications (thirteen pages)
Appellant’s Exhibits:
Exhibit 1 – State Hearing Request (one page)
Exhibit 2 – Narrative (eight pages)
Exhibit 3 – Letter from Physical Therapist (one page)
Exhibit 4 – Letter from Nursing Supervisor (two pages)
Exhibit 5 – Pictures of Appellant (two pages)
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