State Hearing Decision - Hearing Decisions

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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