Source: https://www.eldersection.org/fair-hearings-reports/medicaid-denials/
Timestamp: 2020-08-14 20:23:22
Document Index: 341800672

Matched Legal Cases: ['§ 409', '§409', '§ 59', '§ 409', '§ 438', '§ 409', '§ 430', '§ 409', '§ 483', '§ 483', '§409', '§447', '§447', '§423', '§409', '§409', '§65', '§ 416', '§416', '§416', '§ 65', '§ 65', '§ 416', '§ 1396', '§416', '§416', '§ 409', '§ 65', '§ 409', '§ 65', '§ 409', '§ 65', '§ 409', '§ 65', '§409', '§205', 'art 03', '§416', '§409', '§409', '§409', '§409', '§409', '§409', '§120', '§409', '§409', '§409', '§430', '§431', '§431', '§408', '§408', '§409', '§440', '§409', '§409', '§ 65', '§ 65', '§ 65', '§ 65', '§ 65', '§1640', '§65', '§ 435', '§65', '§409', '§409', '§440', '§1396', '§409', '§409', '§409', '§440', '§409', '§409', '§409', '§409', '§409', '§409', '§440', '§440', '§440', '§440', '§440', '§440', '§440', '§440', '§409', '§440', '§409', '§1396', '§1396', '§409', '§409', '§409', '§409', '§409', '§409', '§440', '§409', '§409', '§409', '§1396', '§1396', '§409', '§409', '§409', '§440', '§440', '§409', '§409', '§440', '§409', '§409', '§409', '§409', '§409', '§409', '§409', '§409', '§409', '§409', '§1396', '§1396', '§409', '§409', '§409', '§409', '§440', '§440', '§409', '§1396', '§409', '§409', '§65', '§ 416', '§65']

Medicaid Denials | Elder Law Section of the Florida Bar
Medicaid / Government Benefits
Fair Hearings Reports
Return to All Fair Hearing Reports
Excess Assets/Resources
Failure to Submit Requested Information
Failure to File a Timely Appeal
Failure to Cooperate in Establishing Eligibility
Information Insufficient to Establish Eligibility
Failure to Properly fund QIT
Failure to Establish QIT
Prior Authorization Decisions
Parent/Caregiver Responsibility
Burden of proof is on the Department when action reduces or terminates benefits, Fla. Admin. Code 65-2.060- 09F-02042
Burden of proof is on the Petitioner when application for benefits or payments is denied, Fla. Admin. Code 65-2.060- 09F-02042
The party having the burden shall establish his position by a preponderance of evidence, to the satisfaction of the hearing officer, Fla. Admin. Code 65-2.060- 09F-03735
The petitioner’s hearing was considered to be abandoned when the hearing officer waited for 30 minutes at the hearing and neither the petitioner, the petitioner’s representative or the ombudsman appeared at the hearing. There was no contact from the petitioner or the petitioner’s representative. Fla. Admin. Code R. 65-2.061- 12N-00002
The Department’s action of reducing the petitioner’s personal care services where the petitioner was currently receiving respite services through the Medicaid Waiver program. And Medicaid reimburses services that do not duplicate another provider’s service. Fla. Admin. Code, 59G-1.010(166)- 11F-06606
The Department’s action of not allowing the petitioner’s HMO to pay for the petitioner’s speech therapy was upheld where the petitioner made the request outside of the open enrolment period and the petitioner failed to meet the burden of showing that the change would be made for good cause Fla. Stat. § 409.912, §409.969 –11F-07360
The respondent’s action of denying the petitioner request for reimbursement for privately paid SNF care was upheld where the respondent was not responsible for the cost of the non-emergency SNF care because it was contracted for by the facility. Fla. Stat. ch. 430.705, Fla. Admin. Code § 59G-13.080- 11F-07415
The respondent’s action of denying the petitioner’s disenrollment from the HMO Health Ease was affirmed when the petitioner claimed to not be able to pay her current specialist. The petitioner did not present any evidence that showed that there were no specialists within the allotted driving distance from the petitioner’s home. Therefore, the petitioner failed to meet the burden of proof and the disenrollment from the program was denied. Fla. Stat. 409.912, Fl. Stat. 409.969 –11F-07663
The respondent’s action of denying the petitioner’s requested surgical procedure was affirmed when the petitioner’s requested surgical procedure was not consistent with the generally accepted professional medical standards and was deemed to be experimental and investigational. Therefore, the petitioner’s surgical procedure did not meet the requirements of medical necessity Fla. Stat. § 409.912, § 438.210(a)(2)(iii), Fla. Admin. Code Rule 59G-1.010(166)- 11F-08312
The respondent’s action of denying the petitioner’s request for an additional 10 home care hours per week through the respondent’s Nursing Home Diversion Project was upheld when the petitioner failed to satisfy the burden of proof. The petitioner did not present credible evidence that all the conditions of medical necessity were satisfied in order to justify an increase in service hours. Fla. Stat. § 409.912, Fla. Stat. § 430.705(2)(a), Fla. Admin. Code R. 58N-1.009 – 11F-08980
The petitioner’s request for an EIO Pushchair and accessories was denied because the EIO Pushchair does not have a HCPCS code, which is a Medicaid registration code that is required for all equipment funded through Medicaid. Fla. Admin. Code Rule 59G-1.010(166)- 11F-08791
The petitioner’s request for a commercially prepared enteral nutrition product (formula) was denied when the respondent determined that the supplement was not medically necessary for the petitioner. The formula would have been approved if the petitioner had a medical condition that limited their ability to ingest, digest, or absorb regular food or the product could have been used to augment the petitioner’s normal dietary sources of nutrition. Fla. Stat. 409.912, Fla. Administrative Code Chapter 59G-4- 11F-09775
The petitioner failed to establish a good cause to change his Medicaid Managed Care plan prior to open-enrollment where the petitioner did not submit the required documentation necessary to be authorized to see another physician. Therefore, the petitioner did not demonstrate that he suffered a substantial and unreasonable delay in seeing a physician. Fla. Stat. § 409.969(2), Fla. Admin. Code Rule 59G-8.600 – 12F-01458
The denial of Medicaid ICP benefits was upheld where the respondent did not receive a level of care determination for the petitioner from APS Healthcare via CARES staff. 42 C.F.R. § 483.128 (a), 42 C.F.R. § 483.112 (a)- 11F-00065
The Department’s action to cancel the petitioner’s eligibility for HCBS Medicaid Waiver coverage was affirmed where the petitioner made significant progress in achieving a certain level of independence and medical stability. Based on the petitioner’s medical assessments, the Department concluded that the petitioner no longer met the level of care and the Department terminated the petitioner’s eligibility for HCBS Medicaid Waiver. Fla. Admin Code 59G-4.290, Fla. Admin. Code 59G-4.180- 11F-00126
Petitioner’s eligibility for Medicaid under the Family Planning Waiver was restricted by statute to an additional 24 months regardless of family situation, petitioner’s health or pending medical assistance application, Fla. Stat. §409.904- 09F-04713
Petitioner reached the age of 21 and was therefore properly denied home health aide services for children, Fla. Admin. Code 59G-4.130, Home Health Services Coverage and Limitations Handbook pg. 2-10- 09F-03265
Agency decision denying reimbursement for prescriptions was upheld because, the claim under Medicaid was made more than 12 months after the hearing granting Supplemental Security Income, 42 C.F.R. §447.25, 42 C.F.R. §447.45, Fla. Admin. Code 65A-1.702, F.A.C. 59G-5.110- 09F-06730
Petitioner requested reimbursement for all prescription costs incurred since Medicaid eligibility was determined, including Petitioner’s co-payments. Appeal denied because, direct reimbursement is appropriate only for those expenses covered by Medicaid, 42 C.F.R. §423.906, Fla. Stat. §409.9066, F.S. §409.9081, Fla. Admin. Code 59G-5.110- 09F-06318
The respondent’s action of denying the petitioner’s ICP benefits was upheld when the petitioner, who was living in a nursing home, failed to satisfy the criterion for financial hardship. Fla. Admin. Code §65A-1.702, 65A-1.713- 11F-05216
The denial of ICP Medicaid benefits was upheld when the petitioner’s total countable income of $2,889.17 exceeded the $2,022 maximum income standard for ICP eligibility. Fla. Admin. Code 65A-1.713- 10F-06911
The denial of ICP Medicaid benefits was upheld when the petitioner’s gross monthly income of $2,036 exceeded the income standard for the ICP Medicaid Program of $2,022 for an individual. Fla. Admin. Code 65A-1.713- 10F-06968
The denial of ICP Medicaid Benefits was upheld where the petitioner failed to provide the respondent with adequate income verification from the petitioner’s sources of income. 20 C.F.R. § 416.1100, Fla. Admin. Code 65A-1.205(c)- 11F-00850
The denial of ICP Medicaid benefits was upheld where the petitioner had non-income producing non-homesteaded property with an appraised value at $14,899. The equity value of the property was at least $14,000 and the property was listed for sale. The petitioner exceeded the applicable resource limits to receive benefits for the months at issue. 20 C.F.R. §416.1201, 20 C.F.R. §416.1245- 11F-01016
Petitioner’s family was never notified by the Department that a QIT was needed. Because of the department’s failure to comply with its policy, the denial of ICP benefits must be reversed , Fla. Admin. Code 65A-1.713, Forman v. State of Florida Dep’t of Children and Families, 4D06-1770 (Fla. 4th DCA 2007), Department of Children and Families Integrated Public Assistance Policy Manual passage 1840.0110, Appendix A-9- 09F-03311
Petitioner was not over the income limit until March 2009, when 3 overdue SSA pension checks arrived, therefore denial of ICP benefits due to excess income in January and February 2009 was not upheld, Fla. Admin. Code 65-2.056, F.A.C. 65A-1.713, F.A.C. 65A-1.702, ACCESS Fla. Integrated Public Policy Manual s. 1840.0110- 09F-03827
After outstanding checks were deducted from December account balance, Petitioner was eligible for ICP benefits in that month. However, January income remained in excess of program limits. Petitioner claimed Dept failure to explain eligibility criteria led Petitioner to allow accrual of excess income in account. No authority which directs the Dep’t to advise or instruct applicants on becoming eligible, Fla. Admin. Code 65-2.060, F.A.C. 65-2.066, F.A.C. 65A-1.712, F.A.C. 65A-1.716- 09F-03735
The hearing officer concluded that it is not permissible to use a figure higher than $5,000, which was set by Rule 65A-1.716 (d) as a divisor to determine ineligibility period. Therefore, the Department’s action of dividing the petitioner’s $39, 150 by the $5,000 divisor was upheld and resulted in seven full months of ineligibility. Fla. Admin. Code 65A-1.712- 11F-06449
The denial of ICP Medicaid benefits was upheld when the petitioner’s asset value exceeded the $2,000 asset limit. Fla. Admin. Code 65A-1.712, Fla. Admin. Code 65A-1.716 (5)(a)- 11F-02360
The denial of ICP Medicaid Benefits was upheld when the petitioner’s gross income of $2,031.52 and cash value asset of $8,012 exceeded the income and asset limits for ICP and Medicaid Program benefits. Fla. Admin. Code at § 65A-1.716(2)(b), Florida Administrative Code at § 65A-1.716(5)- 11F-00706
The denial of ICP Medicaid Benefits was upheld when the petitioner’s assets from the cash value of her life insurance policies, after the burial exclusion, exceeded the $2000 asset limit for the ICP Medicaid Program during July 2010 and August 2010. In September 2010, the petitioner purchased the irrevocable burial contract with the cash value of all of the petitioner’s life insurance policies and the petitioner became eligible to receive ICP Medicaid benefits. Federal Medicaid Regulations at 20 C.F.R. § 416.1201, Fla. Admin. Code 65A-1.712- 10F-07517
The denial of ICP Medicaid Benefits was upheld when the petitioner transferred assets totaling $52,000. The penalty period of 10.4 months was determined by dividing the $52,000 by the $5,000 average monthly private pay nursing facility rate. And the penalty period was affirmed and assigned to run from the first month of eligibility. 42 USCS § 1396p(c), Fla. Admin. Code Rule 65A-1.716- 11F-00619
Definition of Assets, Fla. Admin Code 65A-1.303- 08F-07221
Resource limits, Fla. Admin. Code 65A-1.712- 08F-07221
Countable assets are those to which the individual has unrestricted access or those available to a representative for the benefit of the individual, even if the representative choses not to access the asset. Since there were only physical, not legal restrictions to accessibility, the ICP denial for excess income is upheld, Fla. Admin. Code 65A-1.712, F.A.C. 65A-1.716, F.A.C. 65A-1.303, DCF Florida Integrated Public Policy Manual 165-22, passages 1640.0316, 1640.0320, 1640.0319- 09F-03514
ICP application denied for excess income after Petitioner failed to set up a QIT, despite the notice misstating the reason for denial as excess assets. Fla. Admin. Code 65A-1.702(15), F.A.C. 65A-1.713, Department Policy Manual 165-22 Appendix A-9, ACCESS Fla. Program Policy Manual s. 1840.0110- 09F-02789
Petitioner was not comatose, nor were her assets legally encumbered, therefore ineligibility was upheld because petitioner owned stock which caused her to exceed income limits. 20 C.F.R. §416.1201(a), 20 C.F.R. §416.1205(c), Fla. Admin. Code 65A-1.712, F.A.C. 65A-1.716, Florida Integrated Public Policy Manual 165-22, Appendix A-9 and passages, 1640.0205, 1640.0319 and 1640.0408- 09F-04007
Countable value is Petitioner’s equity in asset, measured by value of sale, minus legal debt, including outstanding checks, Florida Integrated Public Policy Manual 165-22 s. 1640.0408- 09F04007
The denial of Medicaid ICP benefits was upheld when the respondent issued to the petitioner a Notice of Case Action denying eligibility due to a failure to receive all of the petitioner’s information. The hearing officer noted that if eligibility is determined at a later date, then eligibility could occur based on the original application date of August 2010. Once the review is completed, further appealable Notice of Case Action will be issued by the respondent. Fla. Stat. § 409.285, Fla. Stat. § 65-2.056. 10F-08051
The denial of Medicaid ICP benefits was upheld when the petitioner failed to establish, by the required evidentiary standard, that the Respondent?s action was not correct. The undersigned concludes the Respondent was correct to deny the petitioner?s ICP Medicaid application as verification of his bank account was not provided. Fla. Stat. § 409.285, Fla. Stat. § 65-2.056. 15F-00527
The denial of Medicaid ICP benefits was upheld when the petitioner when the petitioner failed to provide all of the failed to meet the her burden of proof. Fla. Stat. § 409.285, Fla. Stat. § 65-2.056. 15F-00780
The denial of Hospice Medicaid Program benefits was upheld when the petitioner failed to establish, by the required evidentiary standard, that the Respondent?s action was not correct. The undersigned concludes the Respondent was correct was correct to deny the petitioner?s ICP Medicaid application as verification of his bank account was not provided. Fla. Stat. § 409.285, Fla. Stat. § 65-2.056. 15F-00533
The petitioner’s appeal was dismissed when the petitioner’s action under challenge occurred on August 20, 2009 and the petitioner filed an appeal on December 20, 2010. This was not considered a timely appeal because more than 90 days had lapsed. Fla. Admin. Code 65-2.046- 10F-09146
The petitioner’s appeal was dismissed when the petitioner’s action under challenge occurred on August 11, 2009 and the petitioner filed an appeal on December 20, 2010. This was not considered a timely appeal because more than 90 days had lapsed. Fla. Admin. Code 65-2.046- 10F-09148
The petitioner’s appeal was dismissed after the petitioner received notice that an appeal must be requested within 90 days of the notice of case action and the petitioner failed to file an appeal within the 90 day time period. 11F-02667
The out-of-state provider did not submit a bill to Florida Medicaid and refused to become a Florida Medicaid Provider. Therefore, no denial or delay by the Department has occurred and the appeal is dismissed, 42 C.F.R. 431.200- 09F-02909
Appeal denied where, out-of-state provider was not a Florida Medicaid enrolled provider and therefore could not be reimbursed by Florida Medicaid for emergency services rendered, Fla. Admin. Code 59G-5.010, F.A.C. 59G-5.020, Florida Medicaid Provider General Handbook, pgs. 1-2, 2-36, Florida Medicaid Summary of Services, Section VI, pgs. 68, 77- 09F-06000
The Department’s action of denying the petitioner’s level of care was affirmed when the petitioner met the state definition of mental illness. Therefore, the petitioner was unable to meet the burden of demonstrating PASRR/MI Level II eligibility. Fla. Integrated Pub. Policy Manual, passage 1440.1300, Fla. Admin. Code 59G-4.180- 11F-00069
At hearing, new information concerning Mother, caregiver, was disclosed. However, information was an insufficient basis for finding medical necessity. Case was remanded to respondent to allow for consideration of new information and determination of medical necessity, Fla. Admin. Code 59G-1.010(166), F.A.C. 65-2.056, Home Health Services Coverage and Limitations Handbook (July 2007), pg. 2-17- 09F-05406
Private duty nursing hours denied where Provider submitted parent’s work schedules which were not sufficiently specific. Supplemental information on work schedules could be submitted through a modification request, Fla. Stat. §409.905, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130, Home Health Services Coverage and Limitations Handbook (July 2008) pg. 2-22- 09F-3753
Denial of BSCIP (Brain and Spinal Cord Injury Program) benefits overruled where no non-hearsay proof of Petitioner’s disruptive behavior, alleged drug abuse or written and oral warnings existed. BSCIP Handbook makes no mention that provider safety is a factor with respect to determining medical necessity, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-13.080- 09F-04105
The denial of ICP Medicaid benefits was upheld when the petitioner’s QIT was improperly funded for three months because of a non-cooperative relative, lack of knowledge and subsequently lack of legal authority to access the petitioner’s income and misinformation given by an attorney. The petitioner’s community spouse was not allowed to receive additional funds from the petitioner’s income because the community spouse’s income of $2203.64 exceeded the adjusted shelter and utility expenses of $1211.64. Fla. Admin. Code 65A-1.713, Fla. Admin. Code 65A-1.712- 10F-05088
The denial of ICP Medicaid benefits was upheld when the petitioner’s total gross income of $2041 retained outside the trust exceeded the ICP Medicaid income limitation of $2022, the petitioner was not eligible to receive ICP Medicaid for the months at issue. Fla. Admin. Code 65A-1.710, Fla. Admin. Code 65A-1.713- 10F-08164
Income must be deposited into the QIT in the month in which it was received. Communication problems with depositing entity did not excuse the failure to deposit, Florida Integrated Public Assistance Policy Manual s. 1840.0110, Fla. Admin. Code 65A-1.713- 09F-04608
Sufficient income must be deposited into the QIT each month that coverage is requested to reduce countable income to within the program income standard, Fla. Admin. Code 65A-1.702(15), F.A.C. 65A-1.713, ACCESS Florida Program Policy Manual 165-22, s.1840.0110- 09F-03793
Termination of ICP benefits issue is moot because, the Petitioner failed to fund the QIT. Therefore, benefits were correctly denied. However, the action to increase patient responsibility is reversed because, the Department failed to follow its policy in providing written notification of a change in benefits at least 10 days prior to the effective month of the action, 45 C.F.R. §205.10(a)(4), Fla. Admin. Code 65-2.048(1), F.A.C. 65-2.049, F.A.C. 65A-1.711, F.A.C. 65A-1.714(1), F.A.C. 65A-1.716(5)(c), Fla. Admin. Code 65-2.048(1), F.A.C. 65-2.049, F.A.C. 65A-1.702(15), F.A.C. 65A-1.713, Department of Children and Families Policy Manual 165-22 Appendix A-3.1, A-9 and A-10, DCF’s ACCESS Program Policy Manual, 165-22, section 1840.0110, 2640.0117 and 3440.0100, State Medicaid Manual, Part 03, Eligibility, Section 3700- 09F-06396
Appeal denied. Petitioner had an IRA account, which made payments of $1,687.29 each year. The IRA payment put the petitioner over the income limits for the month in which it was received. Instead of establishing a QIT, petitioner cashed out the IRA, paid the federal withholding taxes and transferred the money to her spouse. Because the transfer was allowable and the countable asset now belonged to the community spouse, petitioner claimed to still be eligible for ICP benefits. However, when petitioner was still receiving payments from the IRA, the balance was considered available unearned income, but was not countable in the asset consideration. When the Petitioner voluntarily took full distribution of the IRA and paid withholding taxes, the unearned income became countable in the month received. The distribution put the petitioner over the minimum income limit and denial of ICP benefits was appropriate, 20 C.F.R. §416.1121, Fla. Admin. Code 65A-1.712, F.A.C. 65A-1.716, ACCESS Policy Manual, 1640.0505.04- 10F-00519
Petitioner failed to disclose amount of nursing home supplemental insurance policy, which was paid directly to Petitioner and is therefore countable as income in the ICP program. No QIT was established so, Petitioner is ineligible based on excess income, Fla. Admin. Code 65A-1.713, ACCESS Fla. Program Policy Manual, 1840.0110 and 1840.1007- 09F-03639
ICP application denied for excess income after Petitioner failed to set up a QIT, despite the notice misstating the reason for denial as excess assets. Fla. Admin. Code 65A-1.702(15), F.A.C. 65A-1.713, Department Policy Manual 165-22 Appendix A-9, ACCESS Fla. Program Policy Manual s. 1840.0110- 09F-02789 [Missing file]
Appeal denied. Petitioner failed to establish and fund both an irrevocable trust and an irrevocable bank account before June 2009, therefore eligibility began in June and not earlier. Fla. Admin. Code 65A-1.701(26), F.A.C. 65A-1.702(15), F.A.C. 65A-1.713, ACCESS Florida Program Policy Manual 165-22, Appendix A-9 and Section 1840.0110- 09F-05738
Definition, Fla. Admin. Code 59G-1.010- 09F-03161
Medical necessity is determined based on information available at the time the goods or services are provided, Fla. Stat. §409.9132(d)- 09F-03333
Two-step inquiry for medical necessity involves whether the petitioner requires the amount of care requested and whether there are other parties, besides private duty nurses, who can provide this care. To determine whether caregiver can provide care, we look to their availability, medical conditions, impact of other responsibilities and skill, Fla. Admin. Code 59G-1.010, F.A.C. 59G-4.130(2), Home Health Services Coverage and Limitations Handbook pg. 2-14 and 2-15- 09F-03162
After denial of Private Duty Nursing services, Petitioner requested reconsideration because mother, primary caregiver, traveled to Cuba and petitioner’s grandmother had been diagnosed with Leukemia. PDN denied on reconsideration because full-time care was not medically necessary, Home Health Services Coverage and Limitations Handbook (July 2008) pg. 2-17 and 2-19, Fla. Admin. Code 59G-1.010- 09F-04842
Request for full-time Private Duty Nursing services denied where Petitioner suffered no seizures, hospitalizations or emergency room visits in the prior certification period (six months). Additional hours could be requested, as needed, when both parents were not available, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130(2), Home Health Services Coverage and Limitation Handbook, pg. 2-15- 09F-04028
Home Health Aid services would be more appropriate where mother, primary caregiver, could not lift Petitioner because of medical condition and where private duty nursing was not medically necessary, Home Health Services Coverage and Limitation Handbook pg. 2-15- 09F-03488
Petitioner requested Home Health Aid (HHA) to make beds, meals and check blood sugar. Desired HHA benefits were not medically necessary and fell under Medicaid exception for mental health and psychiatric services which are covered by the Medicaid Community Behavioral Health Program, Home Health Services Coverage and Limitations handbook (July 2008), Chapter 2- 09F-4110
Additional nursing hours determined to be medically necessary by medical director of private duty nursing at administrative hearing thereby rescinding agency’s initial denial, Fla. Admin. Code 59G-1.010, F.A.C. 59G4.290- 09F-04929
Only two of the services performed by the certified nursing assistant fell within the gambit of companion services, therefore authorized hours were reduced to reflect the actual time spent on those services, Fla. Admin. Code 59G-8.200(g), F.A.C. 59G-13.130, Fla. Medicaid Traumatic Brain and Spinal Cord Injury Waiver Services Coverage and Limitations Handbook pg. 2-27, 1-15- 09F-05014
Teaching services performed by the nurse are not skilled home nursing services. Reduction in petitioner’s skilled home nursing services based on determination of the petitioner’s condition and his parent’s work hours, Fla. Admin. Code 59G4.290, F.A.C. 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-15- 09F-05407
Teaching provided by nurse is not within purview of medically necessary skilled services, Fla. Admin Code 59G-4.290- 09F-02985
Private duty nursing service is that which must be provided by a registered nurse or health care professional. Non-professionals can administer oxygen and babysitting is not covered under Medicaid, Home Health Services Coverage and Limitations Handbook pg. 2-10, Fla. Admin. Code 59G-1.010, F.A.C. 59G-4.290- 09F-04667
Home Health Aid visit is not limited in time, therefore respondent approved one HHA visit a day when visit could accomplish all medically necessary services, Fla. Admin. Code 59G-1.010, F.A.C. 65-2.056, Home Health Services Coverage and Limitations Handbook pg. 1-2- 09F-04641
Without evidence from treating physician as to Petitioner’s condition and diagnosis, customary weight given treating physician’s opinion is overcome. Inpatient hospitalization for hysterectomy surgery is denied despite alleged reduction in quality of life, Florida Medicaid Hospital Services Coverage and Limitations Handbook, ch. 2, Fla. Admin. Code 59G-4.150- 09F-05017
Request for rehabilitation services was denied because Petitioner does not appear to have the capacity to benefit from those services, Fla. Admin. Code 59G-4.160, F.A.C. 59G-1.010, Hospital Services Coverage and Limitations Handbook, “Medical Necessity”- 09F-05408
Additional hours Home Health Aide services under Medicaid long-term care community diversion pilot program denied where petitioner received 9-11 hours daily, no evidence of medical necessity was presented and caregiver previously cancelled Hospice bath times, Fla. Admin. Code 59G-1.010, F.A.C. 59G-4.130, Fla. Stat. §409.912 – 09F-05020
Evidence was submitted, prior to the hearing, which supported the medical necessity of petitioner’s braces. Therefore, prior authorization was granted under the Dental Services Coverage and Limitations Handbook and appeal was dismissed, Fla. Admin. Code 59G-1.010- 09F-04877
Both respondent’s and petitioner’s physicians agreed that petitioner was able to attend daycare and her condition was not severe enough to warrant Prescribed Pediatric Extended Care services, therefore PPEC was not medically necessary, Fla. Admin. Code 59G-1.010, F.A.C. 59G-4.260- 09F-04707
PPEC reduction was not justified where Caregiver’s lawn business and livelihood would be impacted by the loss of part-time PPEC due to nature of seasonal business. Respondent made visit to Caregiver’s home but failed to produce evidence of lack of medical necessity outside of the belief that Caregiver was available to perform duties, Fla. Stat. §409.913, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.260(2), Fla. Medicaid Prescribed Pediatric Extended Care Services Coverage and Limitations Handbook, ch. 1 and 2- 09F-03487
Medicaid does not reimburse Private Duty Nursing services for respite care. Here, attending church and visiting petitioner’s grandmother in an assisted living facility is considered socialization and voluntary activity during which PDN will not be provided, Fla. Stat. §409.919(2006), F.S. §409.905, F.S. §409.913, Fla. Admin. Code 59G-1.010, Home Health Services Coverage and Limitations Handbook pg. 2-19, Appendix B, ch. 2 pg. 2-2 and 2-17- 09F-04251
Decision denying private duty nursing services for 2 hours a day was upheld where Petitioner’s mother and caregiver could care for Petitioner during that time, Fla. Stat. §120.80, Fla. Admin. Code 59G-1.010, F.A.C. 59G-4.290, Home Health Services Coverage and Limitations Handbook pg. 2-15- 09F-04027
Private duty nursing hours denied where Provider submitted parent’s work schedules which were not sufficiently specific. Supplemental information on work schedules could be submitted through a modification request. Fla. Stat. §409.905, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130, Home Health Services Coverage and Limitations Handbook (July 2008) pg. 2-22- 09F-3753
Lifting the petitioner did not require a skilled nurse, therefore additional hours were denied as both parents were home and one was a competent caregiver. Here, father or home health aid would have been less costly treatment to help lift petitioner, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook pg. 2-14, 2-15- 09F-02592
Home health visits were more appropriate than PDN for weekly injection. Lesser level of service was appropriate. Fla. Stat. §409.905, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130, Home Health Services Coverage and Limitations Handbook (July 2008) pg. 2-17, 2-19- 09F-3169
Agency determination upheld where it considered petitioner’s condition and parent’s work hours and determined parents could provide care during the denied hours, Fla. Admin. Code 59G-1.010, F.A.C. 59G-4.290, Home Health Services Coverage and Limitations Handbook pg. 2-15- 09F-03230
Four physicians opine that Petitioner needs 40 hours of HHA services, which he receives from a combination of private HHA and Medicaid. Appeal for increase in Medicaid HHA services denied, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130, Home Health Aid Services and Limitations Handbook pg. 2-14- 09F-03334
Companion services are therapeutic and not diversional in nature. Companion service in excess of petitioner’s need will be denied, Fla. Admin. Code 59G-1.010(166), Traumatic Brain and Spinal Cord Injury Waiver Services Handbook pg. 2-27- 09F-03111
Adult day care was reduced from five to three days a week because the reduced hours were considered adequate for socialization and medical necessity did not require more. To ease transition into ALF, two days of ADC at an ALF was added, Fla. Stat. §409.031, F.S. §430.705, Fla. Admin. Code 59G-1.001, F.A.C. 59G-1.010(166)- 09F-3495
Despite the clear need for in-patient treatment, the petitioner has reached 18 years and is no longer eligible for SIPP benefits. Therefore, no corrective action is available to the hearing officer, despite the failure of the respondent to produce evidence supporting their original determination, Fla. Admin. Code 59G-1.010(166)(a)(c), F.A.C. 65A-1.702(16), AHCA Online Utilization Review Process “Utilization Review,” Fla. Medicaid Summary of Services Handbook 2008-2009- 09F-02523
Appeal rendered moot after petitioner accepted the denial of four hours day in exchange for the respondent agreeing to move the hours to earlier in the day, Fla. Admin. Code 59G-4.130- 09F-03368
An additional hour of Home Health Aid services was not medically necessary where coverage already included daily visits and Appeal board shifted some hours to evening to accommodate petitioner’s schedule, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130, Home Health Services Coverage and Limitations Handbook pg. 2-14- 09F-03614
Petitioner appeals reduction in companion care services under BSCIP of 2 hours 7 days a week. Necessary services can be provided during reduced hours. Appeal denied despite agency’s failure to notify petitioner of denial in writing 10 days in advance because no out of pocket expenses were incurred from failure, 42 C.F.R. §431.206, 42 C.F.R. §431.211, Fla. Stat. §408.301, F.S. §408.302, Fla. Admin. Code 59G-13.080, F.A.C. 59G-13.130, F.A.C. 65-2.060, Fla. Medicaid Summary of Services Handbook Traumatic Brain and Spinal Cord Injury Waiver Services, 2008-2009- 09F-02990
The agency is the final arbiter of medical necessity. PPEC services denied because petitioner’s condition was improving and treating physician used “medical necessity” outside its legal definition, Fla. Stat. §409.913(1)(d), Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.260(2), Fla. Medicaid Prescribed Pediatric Extended Care Services Coverage and Limitations Handbook, Ch. 1 and 2- 09F-03109
Denial of skilled duty nursing service for 2 hours on Sundays is upheld because mother was not working at that time and a Home Health Aid could help with lifting at a lower cost, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-14 and 2-15- 09F-02748
Appeal from denial of prior authorization for orthodontic braces was remanded for further consideration. Request was originally denied because Petitioner’s condition fell below minimum criteria on Initial Assessment Form and it was outside plan of care. However, at the hearing Petitioner introduced evidence that Petitioner’s speech therapy was hindered by misalignment of her teeth, Fla. Admin. Code 59G-1.010(166)- 09F-05279
Respondent agreed to revaluate HHA services denial after mother, primary caregiver, submitted a letter from her chiropractor explaining back pain which prevents her from lifting Petitioner. Denial is not upheld pending reconsideration, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130, Home Health Service Coverage and Limitations Handbook, pg. 2-14- 09F-03161
Father’s potential future employment and mother’s unsubstantiated lifting limitation was insufficient to create medical necessity for PDN services during those hours neither parent worked, Fla. Admin. Code 59G-1.010(166), F.A.C. 65-2.060, Home Health Services Coverage and Limitation Handbook, pg. 2-14, 2-15, HHS Coverage and Limitation Handbook (July 2008), pg. 2-17, 2-19- 09F-02042
Agency denied continuation of home health services because they were intended to be temporary and Petitioner’s advanced Alzheimer’s condition, husband’s work schedule and his ability to care for petitioner necessitated adult day care services, Fla. Admin. Code 59G-1.010, F.A.C. 59G-4.130, Home Health Services and Limitations Handbook, pg. 2-14- 09F-03613
Denial of SIPP benefits for extension of inpatient treatment was appropriate because continued treatment would not improve petitioner’s condition, Florida Medicaid Summary of Services Handbook 2008-09, Statewide Impatient Psychiatric Program (SIPP), Fla. Admin. Code 65A- 1.702(16), Agency for Health Care Administration Online Utilization Review Process- 09F-04712
Companion services cannot be purely diversional. Therefore, reduction in companion services appropriate when both Petitioner’s mother, the primary caregiver, and companion services provider lived with Petitioner, Fla. Admin. Code 59G-8.200, Fla. Admin Code 59G-13.130, Florida Medicaid Traumatic Brain and Spinal Cord Injury Waiver Services Coverage and Limitations Handbook pg. 2-27- 09F-04192
Physical therapy after Achilles tendon surgery was not medically necessary because, petitioner was being treated for poor coordination which was not subject to significant improvement and petitioner had reached full post-operative potential, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.160- 09F-06246
All HHA hours were denied where Petitioners were bilaterally deaf but, had received cochlear implants. They were attending day care and mother’s care was supplemented by aunt’s care, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook (July 2008), pg. 2-22- 09F-07168, 09F-07169
At the hearing, Respondent’s physician reversed original denial and approved eight hours a week of HHA. Petitioner’s request for reinstatement of full forty hours was denied because, caregiver did not work or attend school and was available to provide care. Hearing officer determined that no evidence on the proper number of hours was presented. While forty hours a week was excessive, care was medically necessary and eight hours was insufficient. Therefore, the decision was remanded for further consideration, Fla. Admin. Code 59G-4.130, F.A.C. 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-15- 09F-07504
Appeal denied. Without evidence that more conservative treatment options were tried, treating physician’s opinion is overcome and Petitioner’s request for hysterectomy services is not medically necessary, Fla. Admin. Code 59G-4.150, Hospital Services Coverage and Limitations Handbook (June 2005), pg. 2-1, 2-2, C.F. v. Department of Children and Families, 934 So.2d 1(2005)- 09F-08659
Appeal denied. PDN services denied because, Petitioner was capable of administering his own insulin shots, with additional training, despite his morbid obesity and lack of dexterity, Fla. Admin. Code 59G-1.010(166), F.A.C. 65-2.056, Home Health Services Coverage and Limitations Handbook (July 2008), pg. 2-3- 09F-07773
PDN neither administers petitioner’s medicine nor provides therapy. Therefore, PDN care amounts to babysitting, which is not covered by Medicaid, 42 C.F.R. §440.230(d), Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.290, Home Health Services Coverage and Limitation Handbook, pg. 2-17, 2-10, 2-19- 09F-06937
Appeal denied. Petitioners suffer from severe autism and mother is disabled. Respondent denied all hours after determining petitioners were using PDN services for behavior management, which is not considered medically necessary or covered under the PDN program, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-22- 10F-00937
Appeal granted. Petitioner’s personal care assistance ceased being provided under the Medicaid Developmental Disabilities Waiver Program and was now provided under the state Medicaid plan. Because of this change, Respondent reviewed Petitioner’s case under Medicaid Home Health Services rules.
Medicaid requires two considerations when determining whether an individual qualifies for services. It must be determined whether the service is approved or excluded under the state Medicaid plan regardless of individual need and whether the service is medically necessary. To determine whether the service is provided under Medicaid, the hearing officer looked to the definition of the requested services. Petitioner suffered from autism, which meets the medically complex definition of a chronic debilitating disease of one or more physiological or organ system, in his case the neurological system, which makes him dependent on 24-hour-per-day care. Since Petitioner’s condition is not a mental health condition, but a neurological disorder, it is not excluded from home services. Respondent’s alternative to providing PCA services, Community Behavioral Health Services specifically excludes autism from coverage.
Therefore, Petitioner’s PCA services are approved under Medicaid pending an inquiry into medical necessity. The hearing officer used the Early and Periodic Screening, Diagnosis, and Treatment Services definition of services for children in conjunction with the Florida Administrative Law definition because, the state definition did not “encompass the assistance a caretaker would need in taking care of a disabled child,” C.F. v. Children and Families, 934 So.2d 1, 5 (3d DCA 2005). Only the first condition of medical necessity was examined and Petitioner met it because he cannot perform his ADLs without assistance. Finally, the parents participated as fully as possible considering the father provided all morning care and household responsibilities prevented provision of individual care to Petitioner in the evening, Fla. Stat. 409.905, Fla. Admin. Code 59G-1.010(164), F.A.C. 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-22, 2-15, 2-10, Community Behavioral Health Services Handbook, pg. 1-2, 2-1-4, C.F. v. Children and Families, 934 So.2d 1, 5 (3d DCA 2005), Cook v. AHCA, 967 So.2d 1002, 1004 (1st DCA 2007)- 09F-08159
Power recliner for petitioner’s wheelchair was not medically necessary where manual recliner was less expensive and no evidence was offered from licensed physical therapist to support power recliner over manual equivalent, Fla. Admin. Code 59G-1.010(72), F.A.C. 59G-1.010(166), F.A.C. 59G-4.070, Fla. Medicaid Durable Medical Equipment and Medical Supply Services Coverage and Limitations handbook Agency for Health Care Administration, July 2008- 09F-01862
Respondent considered Durable Medical Equipment, a pulsed irrigated evacuation system, experimental because its efficacy in Petitioner’s ailment had yet to be clinically proven; No rebuttal was offered showing desired treatment was favored over traditional treatments for chronic constipation, Fla. Admin. Code 59G-1.010(166)(a), DME and Medical Supply Services Coverage and Limitations Handbook, pg. 2-96- 09F-04843
Reduction from 4 to 3.5 hours of companion service is reversed because of frequent hospitalization of petitioner attributable to medical stability problems. However, Petitioner is limited to 4 hours of personal care and 6 hours of companion services each day under the rules of the Program, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-13.130, F.A.C. 59G-8.200(3)(p), F.A.C. 59G-8.200(g), Fla. Medicaid Traumatic Brain and Spinal Cord Injury Waiver Services Coverage and Limitations Handbook, pg. 2-36, 2-27- 09F-05334
Due to the failure of the waiver support coordinator to relay information to the agency, the agency neither approved nor denied Petitioner’s request for prior authorization of medical equipment. A hearing is, therefore, premature. Fla. Admin. Code 65-2.056- 09F-01722
Helmet to correct symmetry of infant skull not medically necessary because the cranial index of symmetry (CIS) did not fall below reimbursement requirement (>83), Fla. Admin. Code 59G-4.070, Fla. Medicaid Durable Medical Equipment and Medical Supply Services Coverage and Limitations Handbook Agency for Health Care Administration, July 2008 on Custom Cranial Remolding Orthosis- 09F-03956
Petitioner requested prior authorization for inpatient hospital medical services. Request was initially denied, but upon reconsideration the respondent granted the request and offered an additional 15 days of coverage. Therefore, the matter is resolved and appeal is dismissed, Fla. Admin. Code 59G-1.010- 09F-05349
Petitioner failed to prove breast reduction surgery for back pain was medically necessary when overall weight loss would be more beneficial. Prior authorization denial was upheld, Fla. Admin. Code 59G-1.010(166), Physicians Services Coverage and Limitations Handbook, pg. 2-128- 09F-07170
Agency denied prior authorization for prescription medication where, Petitioner failed to provide documentation explaining the alleged unsuitability of the generic version for treatment. Petitioner also requests reimbursement of copying costs and an award for pain and suffering for being without Oxycontin for 9 days. These claims are denied, as there is no basis for a hearing unless Medicaid benefits have been denied, Fla. Stat. §409.912, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-1.010(226)- 09F-06238
Petitioner’s request for a continuous glucose monitor was denied because, it was not listed under the Florida Medicaid durable medical equipment fee schedule. However, the fee schedule has a miscellaneous category, which requires a finding of medical necessity, for such instances. Since there is no policy requiring Durable Medical Equipment requests to have a specific code related to a specific item, the case was remanded to respondent for consideration under miscellaneous category, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.070, F.A.C 59G-1.010(226), Durable Medical Equipment/Medical Supply Services Coverage and Limitations Handbook (June 2008), pg. 2-3, 2-16 and 2-18 through 2-19- 09F-06954
Petitioner denied prior authorization for removable partial dentures. Partial dentures are authorized only if less than eight teeth are in occlusion. There are no exceptions for esthetics or convenience. Petitioner had ten teeth in occlusion and was missing only four. Therefore Petitioner did not meet standard for medical necessity, Fla. Admin. Code 59G-4.060, Florida Medicaid Dental Services Coverage and Limitations Handbook, Removable Prostheodontics, pg. 2-32- 09F-06941
Decision denying prior authorization for orthodontic services upheld where Petitioner’s condition did not meet the minimum score on the assessment form and where maloccusion did not create a disability or physical impairment to development, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.060, Florida Medicaid Dental Services Coverage and Limitations Handbook, pg. 2-14, 2-16- 09F-07057
Appeal granted. Respondent denied prior authorization for wheelchair because, the request exceeded plan maximums. Evidence was presented, at the hearing, that Medicaid had not purchased the old wheelchair. Respondent, then, argued that exceeding plan maximums was only one factor in the denial and that the chair was not medically necessary. Medical equipment provider testified that the chair could not be modified, at less cost than replacement, to accommodate Petitioner’s massage treatment. Treatment required a reclining chair therefore, a new wheelchair was medically necessary, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.070, Durable Medical Equipment/Medical Supply Services Coverage and Limitations Handbook (July 2008), pg. 2-90, 2-93- 09F-07056
Appeal denied. Petitioner’s request for prior authorization of a power wheelchair was denied. The requested POV was more convenient but, there existed an equally effective, less costly alternative, in a manual wheelchair, which would better maneuver around Petitioner’s house, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-1.010(226), F.A.C. 59G-4.070, Durable Medical Equipment/Medical Supply Services Coverage and Limitations Handbook (July 2008), pg. 2-94, 2-93- 09F-07289
Appeal denied. Respondent denied prior authorization for a Augmentative and Alternative Communication system because Petitioner was able to communicate effectively through a less costly alternative, an alphabet board and communication book, Fla. Stat. §409.913(1)(d), Fla. Admin. Rule 65-2.060(1), Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.070, Durable Medical Equipment/Medical Supply Services Coverage and Limitations Handbook (July 2008), pg. 2-36, 2-37- 09F-07952
Upon receiving additional information, request for prior authorization for inpatient stay was approved- 10F-00342
The petitioner’s appeal to reduce the amount of her Institutional Care Program (ICP) Medicaid patient responsibility was denied because the ICP Medicaid program does not recognize a deduction for a financial obligation such as a mortgage payment. Therefore, there was no provision for the ICP eligible individual to continue to make her mortgage payment once entering the nursing home. Fla. Admin. Code 65A-1.701, 65A-1.713 (3), The Department’s Manual, 165-22, section 0240.0102- 11F-08633
The respondent’s determination of the petitioner’s patient responsibility was affirmed when the petitioner’s total gross monthly income was subtracted by the personal need allowance. The hearing officer determined that the patient responsibility was calculated correctly and the petitioner’s patient responsibility amount was upheld. Fla. Admin. Code § 65A-1.713, § 65A-1.714- 11F-08721
The respondent’s determination of the petitioner’s patient responsibility was affirmed when the petitioner’s total $2,091.66 monthly income for the months of February 2012 and after was subtracted by a $35 monthly personal need allowance. The hearing officer determined that the patient responsibility was calculated correctly and the petitioner’s patient responsibility amount was upheld. Fla. Admin. Code § 65A-1.713, § 65A-1.714- 12F-00460
The findings of fact showed that the money the petitioner received from the irrevocable trust was available to the petitioner as disposable income. Therefore, the Department’s action of including the petitioner’s irrevocable trust money as income in the Department’s determination of the petitioner’s patient responsibility to the Center was affirmed. Fla. Admin. Code § 65A-1.702(15), ACCESS Florida Program Policy Manual 165-22 §1640.0576.03- 11F-01174
The findings showed that the Department calculated the petitioner’s patient responsibility when the Department excluded expenses for nursing facility services rendered prior to Medicaid eligibility. The expenses were determined to be an uncovered medical expense deduction in the calculation of patient responsibility under the statute. 42 C.F.R. 435.725, Fla. Admin. Code 65A-1.7141- 11F-01322
The Department’s determination of the petitioner’s patient responsibility was upheld when the petitioner’s wife failed to submit evidence of changes in her income. The hearing officer noted that once the petitioner submitted evidence of the petitioner’s change in income, the patient responsibility issue would be revisited. Fla. Admin. Code §65A-1.716(5)(c)- 11F-02784
The Department’s determination of the petitioner’s patient responsibility was upheld when the petitioner’s reapplication did not indicate any allowable deductions. Therefore, the patient responsibility equaled the petitioner’s income minus the personal needs allowance, which was justified under the statute. Fla. Admin. Code at 65A-1.203, Fla. Admin. Code at 65-2.043- 11F-03329
The petitioner’s patient responsibility amount was affirmed when the respondent excluded past bills incurred for nursing facility services because they were not recurring expenses for the months of ICP Medicaid eligibility. 42 C.F.R. § 435.725, Fla. Admin. Code §65A-1.714- 11F-04586
Parents must participate in providing care to the fullest extent possible, Medicaid Home Health Services Coverage and Limitation Handbook, July 2008 pg. 2-17 and 2-19- 09F-02042
Parent’s competency for providing care is determined by assessing the skill of the parents and the impact of other household responsibilities. Request must reflect the level of service which can safely be provided and for which no more conservative, less costly replacement is available, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130, Home Health Services Coverage and Limitation Handbook, pg. 2-15, 2-14- 09F-04879
Denial of private duty nursing services was upheld for hours when Petitioner is not in school. No evidence was provided to show care for petitioner would detract from care for other children and petitioner’s father is able and currently available to provide care, Home Health Services Coverage and Limitations Handbook, pg. 2-15, Fla. Admin. Code 59G-1.010- 09F-04709
Appeal for an additional hour of private duty nursing is granted when parents must shower after work and prepare the family meal before providing care to Petitioner, Home Health Services Coverage and Limitation Handbook pg. 2-14 and 2-15, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130- 09F-04315
Private duty nursing services are intended to supplement parental care however, full-time care is medically necessary when Petitioner’s father is not able to safely provide care due to his health conditions and need for further training, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130(2), Home Health Services Coverage and Limitations Handbook pg. 2-15- 09F-04303
Caregivers received training on caring for the Petitioner and could do so when not at work, therefore the decision to deny prior authorization for private duty nursing service is upheld, Fla. Admin. Code 59G-1.010, F.A.C. 59G-4.290, F.A.C. 59G-4.130(2)- 09F-04924
Caregiver is available, despite working, having a medical condition and caring for another child with a blood condition. However, she is not sufficiently trained to provide care considering Petitioner’s frequent and rapid changes in condition. Fla. Admin. Code 59G-1.010, F.A.C. 59G-4.130(2), Home Health Services Coverage and Limitations Handbook pg. 2-14 and 2-15- 09F-03162
Private duty nursing will be decreased over time as caregiver becomes better able to care for Petitioner. Reduction of one hour a weekday is upheld as within parental responsibilities, Fla. Stat. §409.905, Fla. Admin. Code 59G-1.010, Home Health Services Coverage and Limitations Handbook (July 2008), “Covered Services, Limitations and Exclusions”- 09F-04112
Respondent lacked complete information because of limits of I-Exchange fields and mother could not care for Petitioner and 4 other children without father present. PDN was denied for hours when both parents were home, Fla. Admin. Code 59G-1.010, F.A.C. 59G-4.130(2), Home Health Services Coverage and Limitation Handbook pg. 2-14, 2-15- 09F-02664
Mother, primary caregiver, was competent and available to care for petitioner when both she and husband were at home. Appeal for more PDN time to care for herself and home was denied, Fla. Stat. §409.905(4)(b), Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130, Home Health Services Coverage and Limitations Handbook (July 2008) pgs. 2-17, 2-19- 09F-2518
Father not able to provide care. Mother, primary caregiver, provided could provide care but, needed assistance with lifting the petitioner. PDN was not medically necessary to perform lifting, 42 C.F.R. §440.230, 42 U.S.C. §1396d(r)(5), Fla. Admin. Code 58G-1.010(149), F.A.C. 59G-1.010(166), F.A.C. 59G-4.130(2), Fla. Stat. §409.905, F.S. §409.913, Florida Medicaid Child Health Check-up Coverage and Limitations Handbook (Oct. 2003) pg. 1-1, Florida Medicaid Home Health Services Coverage and Limitations Handbook pg. 2-14, 2-15, 2-19- 09F-03369
Respondent did not meet burden of proof that mother, primary caregiver, could provide 16 hours of care on the weekends. And, an extension of 180 days was granted within which mother would continue training to provide safer care, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitation Handbook pg. 2-15- 09F-02705
In addition to 24 hour care Monday through Saturday and mother providing care Sunday from 2 p.m. to 10 p.m., 60 days of 24/7 PDN care was approved where caregiver lacked practical experience and emotional fortitude to address petitioner’s health crashes, Fla. Stat. §409.905, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130, Home Health Services Coverage and Limitations Handbook (July 2008) pg. 2-17, 2-19- 09F-3615
PDN hours were supplemented with home health aid services to provide 24 hour/day assistance; Mother can care for petitioner when health permits therefore, HHA and PDN combination is upheld, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitation Handbook, pg. 2-14, 2-15, 2-19- 09F-05174
Home health care hours are reduced as parents learn more and become more competent caregivers. Household responsibilities did not prevent Mother from safely caring for Petitioner when not working, 42 C.F.R. §440.230(d), Fla. Admin. Code 59G-1.010(166), Fla. Medicaid Home Health Services Coverage and Limitations Handbook, pg. 2-15, 2-19- 09F-05409
At hearing, new information concerning Mother, caregiver, was disclosed. Mother had been declared disabled by SSA and was currently pregnant. Case was remanded to allow for consideration of new information and determination of medical necessity, Fla. Admin. Code 59G-1.010(166), F.A.C. 65-2.056, Home Health Services Coverage and Limitations Handbook (July 2007), pg. 2-17- 09F-05406
Respondent amended original denial because mother’s heart surgery prevented her from providing care or transportation of Petitioner to and from school. However, decision was not reconsidered until after the certification period had passed, rendering it moot, Fla. Admin. Code 59G-1.010(166), F.A.C. 65-2.056(3), Home Health Services Coverage and Limitations Handbook (July 2008), pg. 2-2- 09F-05498
Decision reversed where Mother, primary caregiver, took classes during the denied hours and therefore could not care for petitioner, Fla. Stat. §409.9132(d), Fla. Admin. Code 59G-1.010(166), Fla. Medicaid Home Health Services Coverage and Limitations Handbook, pg. 2-17- 09F-03264
Denial of PDN hours upheld because mother and father were trained in care and present in home even where father would be asleep during hours and there were two other children in household, Fla. Stat. §409.905(4)(b), F.S. §409.913(1)(d), F.S. §409.913(5), Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130(2), Home Health Services Coverage and Limitations Handbook, pg. 2-15, 2-19- 09F-04589
Without written statement or withdrawal of appeal, hearing officer issued a final order affirming agreement in which Respondent approved PDN hours when petitioner is not in school and voided previous reduction in hours- 09F-05177
Appeal denied where respondent’s two reviewing physicians determined mother can provide care for four hours a day even when mother works, father is a full-time student with a traumatic brain injury and another minor child with severe OCD lives in the home. Nurse provided training to parents during HHA hours, Fla. Admin. Code 59G-1.010(166), F.A.C. 59-4.290, Home Health Services Coverage and Limitations Handbook, pg. 2-15- 09F-02985
Mother’s arthritis and chronic shoulder pain did not mandate an increase in HHA hours where there was no medical documentation for injury and no evidence to support mother’s concern that reduced hours were not sufficient to accomplish required tasks, Fla. Admin. Code 59G-4.130, F.A.C. 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-15- 09F-03498
Father’s work schedule changed and Grandmother no longer able to care for other children in household. Therefore, PDN services approved for all times when caregiver is working. PDN hours for petitioner’s twin were not affected by this decision even though they require the same level of care, Fla. Stat. §409.9132(d), Fla. Admin. Code 59G-1.010(166), Fla. Medicaid Home Health Services Coverage and Limitations Handbook, pg. 2-17- 09F-03333
Full skilled home nursing care was not medically necessary, even though Petitioner lives with father who is on call 24/7 because both parents are competent caretakers, respondent had already increased the care from 22/7 to 23/7 on a previous appeal and mother visits 3-4 times a week. Reduction from 24/7 to 23/7 was valid, Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.290, Home Health Services Coverage and Limitations Handbook, pg. 2-15- 09F-03958
Where Petitioner’s father works but mother does not, hearing officer upheld only 2 hours each weekday of home health aid services as medically necessary despite father working every Saturday, Fla. Admin. Code 59G-1.010- 09F-04193
Additional nursing hours not medically necessary because Petitioner’s mother is home during those hours and is a registered nurse trained in caring for Petitioner, Fla. Admin. Code 59G-1.010, F.A.C. 59G4.290, Home Health Services Coverage and Limitation Handbook, pg. 2-15- 09F-04194
Due to petitioner’s size and the complexity of his condition, his mother as primary caregiver, cannot provide sufficient care without Private Nursing services, Fla. Medicaid Home Health Services Coverage and Limitations Handbook pg. 2-17, Fla. Admin. Code 59G-1.010, F.S. §409.9132(d)- 09F-02519
Private Duty Nursing services were approved for when the mother, primary caregiver, was working or asleep and petitioner was in school. Additional hours were not medically necessary because they would supplant the care provided by mother instead of supplementing it, Fla. Admin. Code 59G-1.010, Florida Medicaid Home Health Services Coverage and Limitations Handbook (July 2008), pg. 2-17- 09F-03165
Appeal denied where mother did not work and could care for Petitioner outside of authorized PDN hours. If mother has additional evidence, it should be submitted for reconsideration, 42 C.F.R. §440.230(d), Fla. Admin. Code 58G-1.010(166), Home Health Services Coverage and Limitations Handbook (July 2008), Covered Services- Private Duty Nursing- 09F-06113
Reduction of PDN care by 2 hours a day was upheld. Mother requested the additional hours so time could be spent with her two other children. Babysitting services are not within the scope of medical necessity, 42 C.F.R. §440.230(d), Fla. Admin. Code 58G-1.010(166), Home Health Services Coverage and Limitations Handbook (July 2008)- Private Duty Nursing- 09F-07673
Decision to eliminate skilled home nursing services upheld where mother, primary caregiver, was not employed and her ability to care for Petitioner to the fullest extent possible rendered skilled home nursing services unnecessary, 42 C.F.R. §440.230(d), Fla. Admin. Code 59G-1.010(166), Florida Medicaid Home Health Services Coverage and Limitations Handbook, pg. 2-15, 2-19- 09F-07360
Appeal denied. Twenty-four-hour care was needed, but was denied to allow parents to provide care to the fullest extent possible. Parents’ work schedule and two minor children were considered when determining parents’ ability to provide care, 42 C.F.R. §440.230, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 1-2- 09F-06838
While 24-hour care is needed, home health services are available only to supplement care provided by the caregiver. Appeal is denied, where mother could provide care during hours denied by Medicaid, 42 C.F.R. §440.230(d), Fla. Admin. Code 59G-1.010(166), Florida Medicaid Home Health Services Coverage and Limitations Handbook, pg. 2-15 and 2-19- 09F-07060
Decision denying 312 requested hours was upheld, where 24-hour care was needed but, grandmother could provide care during denied hours, 42 C.F.R. §440.230(d), Fla. Admin. Code 59G-1.010(166), Florida Medicaid Home Health Services Coverage and Limitations Handbook, pg. 2-15 and 2-19- 09F-06854
After considering mother’s school study schedule and medical necessity, Respondent determined that reduction in hours was appropriate. Decision upheld where, agency met their burden of proof and mother had sufficient training to safely provide care, 42 C.F.R. §440.230(d), Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.290, Home Health Services Coverage and Limitation Handbook, pg. 2-17, 2-19- 09F-06850
Decision upheld. The agency met its burden of proof. At the hearing, Respondent added four more hours a week of PDN care and provided for split shifts to allow the mother more time to rest, in light of her circumstances, 42 C.F.R. §440.230(d), Florida Medicaid Home Health Services Coverage and Limitation Handbook, pg. 2-15, 2-19, Fla. Stat. §409.913(1)(d), Fla. Admin. Code 59G-1.010(166)- 09F-05908
Petitioner requested a two hour reduction in daily home health aide services, but Respondent approved a six hour reduction. While changes in aide services are usually gradual to allow the caregiver time to adjust, this reduction corresponded to the mother’s volunteer hours, which are not covered by HHA services under the HHA Handbook, 42 C.F.R. §440.230(d), Fla. Admin. Code 58G-1.010(166), Home Health Services Coverage and Limitation Handbook (July 2008), “Covered Services, Limitations, and Exclusions: Private Duty Nursing”- 09F-07567
Medical necessity was demonstrated for 24-hour care, however, the mother can provide care for two hours a day, after work. Therefore, the reduction in PDN is upheld, allowing the mother to provide care to the fullest extent possible, Fla. Stat. §409.905(4), Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-15- 09F-07293
Appeal denied. Petitioner’s care was not no so complex as to preclude grandmother, primary caregiver, from providing care while PDN or HHA was not present, 42 U.S.C. §1396d(r)(5), 42 U.S.C. §1396d(a)(8), Fla. Stat. §409.913, F.S. §409.905(4)(b), Fla. Admin. Rule 65-2.060(1)(3), Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-17- 09F-07465
Petitioner shared HHA services with a sibling. Decision to deny 3 hours a day of HHA services, from 8 p.m. to 11 p.m., was upheld, where Petitioner was put to bed by 8:30 p.m. and mother was capable of providing care, Fla. Stat. §409.905, Fla. Admin. Code 59G-4.130, Home Health Services Coverage and Limitations Handbook (July 2008), pg. 2-10 and 2-15- 09F-6115
Petitioner shared HHA services with a sibling. Decision to deny 3 hours a day of HHA services, from 8 p.m. to 11 p.m., was upheld, where Petitioner was put to bed by 8:30 p.m. and mother was capable of providing care, Fla. Stat. §409.905, Fla. Admin. Code 59G-4.130, Home Health Services Coverage and Limitations Handbook (July 2008), pg. 2-10 and 2-15- 09F-6114
Reduction of two hours a day was upheld. Petitioner’s mother could not provide evidence that household duties precluded her ability to provide care during those hours. PDN services are not available for respite care, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-15- 09F-07610
Appeal denied. PDN services were reduced to allow Petitioner’s mother to provide care to the fullest extent possible. Respondent extended 24-hour PDN services for a 90-day period to allow mother to find employment. No employment was found, therefore, reduction stands, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-15- 09F-07733
Appeal granted. Given her present responsibilities, including two jobs and caring for Petitioner’s two siblings on less than 3 hours of sleep, mother could not provide additional care safely, Fla. Stat. §409.905, F.S. §409.913(1)(d), Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130, Home Health Services Coverage and Limitations Handbook, pg. 2-17, 2-19, 2-14, 2-15- 09F-06833
Appeal granted. Decision reducing PDN services did not provide for the mother to attend to Petitioner’s sick siblings or allow for adequate rest. Hearing officer determined PDN hours, which allow mother to provide fullest care possible, considering other responsibilities, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-15, 2-19- 09F-06773
Appeal denied. Parents are both employed in the medical field and neither their work schedules, nor their household responsibilities preclude providing care, 42 C.F.R. §440.230(d), Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 1-2- 09F-07907
Appeal denied. Grandmother is capable of care when she is available. Additional PDN and HHA hours were added on Friday to provide time for errands and to assist with the more physically demanding aspects of care, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-15- 09F-06938
Appeal denied. Mother is capable of providing four hours a day of care. Repositioning does not require skilled nursing services and can be covered by less costly HHA services without sacrificing the level of care. Respondent allowed for one month transition into reduced care, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-15, 2-14- 09F-06228
Parents are available to provide care. After 60 day period of training, PDN services can safely be reduced to allow parents to provide fullest extent of care possible, Fla. Stat. §409.905, F.S. §409.913(1)(d), Fla. Admin. Code 59G-1.010(166), Florida Medicaid Home Health Services Coverage and Limitations Handbook, pg. 2-17, 2-19, 2-14, 2-15- 09F-07774
Decision upheld. Father confirmed accuracy of hours considered. Parents were available to safely provide care, Fla. Stat. §409.905, Fla. Admin. Code 59G-4.130, Home Health Services Coverage and Limitations Handbook (July 2008), pg. 2-10, 2-15- 09F-7291
PDN reduction was upheld even when mother began attending school twice a week. Taking into consideration mother’s school, parents would still be able to provide care during designated hours, 42 U.S.C. §1396d(r)(5), 42 U.S.C. §1396d(a)(8), Fla. Stat. §409.913(1)(d), F.S. §409.905(4)(b), Fla. Admin. Rule 65-2.060, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-17- 09F-07295
Appeal denied. Respondent was misinformed of mother’s work hours, however, PDN services could be arranged around her schedule. She had been providing care for 2 hours a day, therefore, she was available, Fla. Stat. §409.913(1)(d), Fla. Admin. Rule 65-2.060, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-17, 2-19- 09F-07955
Appeal denied. Petitioner requested the weekly hours be reduced to allow for HHA during the weekend. Approved hours can be used any way the Petitioner wants, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook (july 2008), pg. 2-2- 09F-06566
Appeal denied. Mother was not working and recently resolved her pending immigration status. She is available and able to perform all services that Petitioner needs, 42 C.F.R. §440.230, Fla Admin. Code 59G-1.010, Home Health Services Coverage and Limitations Handbook (July 2008)- 09F-08727
Decision upheld. Respondent reduced PDN services and allowed a limited training period. Mother was available to provide care but needed to develop her skills, 42 C.F.R. §440.230(d), Fla. Sat. §409. 905, F.S. §409.913(1)(d), Fla Admin. Code 59G-1010(166), Florida Medicaid Home Health Services Coverage and Limitations Handbook (July 2008), pg. 2-17, 2-19- 09F-8192
Mother was concerned over providing care for her two ill children during an emergency. Emergencies cannot be foreseen, therefore, the reduction in PDN hours for both children was upheld. Mother could safely provide 2 hours of care daily for each child and had done so when nurses were unavailable, 42 C.F.R. §440.230(d), Fla. Sat. §409. 905, F.S. §409.913(1)(d), Fla Admin. Code 59G-1010(166), Florida Medicaid Home Health Services Coverage and Limitations Handbook (July 2008), pg. 2-17, 2-19- 09F-8190, 09F-8191
Respondent terminated PDN services after tracheotomy was removed and Petitioner’s situation returned to pre-tracheotomy status. Mother requested overnight PDN services because petitioner vomited in his sleep. However, petitioner’s developmental delays did not alter his reflexive reactions to airway blockage. PDN services were no longer medically necessary, Fla. Stat. §409.9132(d), F.S. §409.905, Fla. Admin. Code 59G-1.010(166), Florida Medicaid Home Health Services Coverage and Limitations Handbook (July 2008), pg. 2-17 through 2-18- 09F-08285
Personal care services, including help with daily living, doctor’s appointments and child care while mother is running errands, was not medically necessary for premature twins. Mother was available and could provide care, Fla. Stat. §409.9132(d), F.S. §409.905, Fla. Admin. Code 59G-1.010(166), Florida Medicaid Home Health Services Coverage and Limitations Handbook (July 2008), pg. 2-22- 09F-07953 and 09F-07954
Full-time care is not medically necessary because, both parents are available 2 hours a day to help with care. PDN services are not permitted during those hours when mother, primary caregiver, is caring for her parents outside the home, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitation Handbook, pg. 2-15, 2-17, 2-19- 09F-07294
Mother’s schedule is unpredictable and inflexible due to her occupation. Therefore, some reduction in PDN hours is justified, but not to the extent previously recommended, Fla. Stat. §409.905, F.S. §409.913(1)(d), Fla. Admin. Code 59G-1.010(166), Florida Medicaid Home Health Services Coverage and Limitation Handbook, pg. 2-17, 2-19, 2-14, 2-15- 09F-08069
Mother must be employed or in school for Petitioner to be qualified for HHA services. HHA services are not medically necessary when used for babysitting or prevention of behavioral problems, Fla. Admin. Code 59G-1.010(166), Florida Medicaid Home Health Services Coverage and Limitations Handbook (July 2008), pg. 2-15- 09F-07175
Respondent approved an additional 2 weekday hours to allow mother to take anti-depression medicine, which makes her drowsy, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook (July 2008) pg. 2-3- 09F-08271
Mother knowledgeable about care, but is disabled and cannot lift Petitioner. HHA can assist mother in providing care when Petitioner is not at school and PDN services are not approved, Fla. Stat. §409.905, F.S. §409.913(1)(d), Fla. Admin. Code 59G-1.010(166), Florida Medicaid Home Health Services Coverage and Limitation Handbook, pg. 2-17, 2-19, 2-14, 2-15. 2-31- 09F-08203
Appeal denied. Reduction was appropriate to allow parents to provide care to the fullest extent possible. Mother could provide care to petitioner, in excess of 80 hours a week, because father could care for second child and performed other household chores. PDN services during mother’s 30 min. daily workout is considered respite care. Burnout was not a concern because, mother was already providing care for 16 hours a day on some days, 42 U.S.C. §1396d(r)(5), 42 U.S.C. §1396d(d)(8), Fla. Stat. §409.913(1)(d), F.S. §409.905(4)(b), Fla. Admin. Code 65-2.060(1)(3), F.A.C. 59G-1.010(166), Moore v. Medows, 324 Fed. Appx. 773 (11th Cir. 2009), McDonald v. Department of Banking & Finance, 346 So.2d 569 (Fla. 1st DCA 1977), Couch Construction Company, Inc. v. Dep’t of Transporation, 361 So.2d 172 (Fla. 1st DCA 1978), Home Health Services Coverage and Limitation Handbook (July 2008), pg. 2-2, 2-10, 2-15- 09F-07732
Appeal denied. Early prevention, screening, diagnosis and treatment services are available to all children receiving Medicaid. Petitioner’s mother is a pediatric nurse practitioner and can provide extra 2 hours of care with assistance from an HHA. She is disabled and cannot lift or reposition the Petitioner alone, Moore v. Medows, 674 F. Supp. 2d 1366 (N.D. Ga. 2009), Fla. Stat. §409.905, F.S. §409.913, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitation Handbook, pg. 2-6, 2-14. 2-15- 09F-07671
Step-down reduction in PDN services was upheld to allow caregiver to provide care to the fullest extent possible and caregiver was required to seek employment, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-15- 09F-07733
During the hearing, new information arose concerning Petitioner’s family situation. Father works in construction and must travel on short notice. Mother provides care to Petitioner and his two siblings. Respondent withdrew previous decision. It was agreed that Respondent would provide 22 hours of PDN services a day while both parents were home and 24 hours of care a day when only one parent was home. Flexibility of father’s schedule was not addressed.- 09F-08478
Appeal granted. Petitioner’s disability causes him to take up to 6 hours a day for activities of daily living. Therefore, both respondent’s initial rejection of all hours and subsequent offer to provide 4 hours a day of Personal Care Assistance under the Developmental Disabilities waiver, were insufficient. Parents give care, when possible, but they are employed and have physical limitations. Any services over 6 hours would be for supervision and safety, which are not factors of medical necessity, Fla. Admin. Code 59G-4.130, F.A.C. 59G-1.010(166), Home Health Services Coverage and Limitation Handbook, pg. 2-22, 23- 10F-00132
Appeal granted. Petitioner’s mother was enrolled full-time in school and care was approved during school and sleep times. Respondent stipulated that it would approve a more gradual step down program to phase Petitioner into less care, reducing care from 24/7 PDN care to 16 hours each weekday and 13 hours on the weekends over 30 day intervals, Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 2-17- 10F-00810
Appeal denied and gradual reduction in Home Health Aide services was approved. Petitioner’s autism causes behavioral problems, for which HHA services are not medically necessary. His mother could care for him, without HHA services, despite working full time, 42 C.F.R. §440.230(d), Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook, pg. 1-2- 10F-00629
Appeal denied. Parents should be trained by the Provider. If the family is not capable of providing any care, then the petitioner does not qualify for the PDN program and care should not be provided at home. Parents were healthy and available to provide 2 hours of care daily, 42 C.F.R. §440.230(d), Fla. Stat. §409.913(1)(d), Fla. Admin. Code 59G-1.010(166), F.A.C. 59G-4.130(2), Florida Medicaid Home Health Services Coverage and Limitations Handbook (July 2008), pg. 2-17, 2-19- 09F-07983
Appeal denied. There are no utilization limits on the amount of PDN services that Petitioner can receive and services are determined based on individual need. Here, Respondent approved 18 hours of HHA and 2 hours of PDN services daily. The Petitioner’s father is capable of caring for her during the remaining time, even considering his ailments and other caretaker responsibilities, 42 U.S.C. §1396d(r)(5), Fla. Stat. §409.913(1)(d), F.S. §409.905(4)(b), Fla. Admin. Code 59G-1.010(166), Fla. Admin. Rule 65-2.060, Home Health Services Coverage and Limitations Handbook, pg. 2-17- 10F-00074
The Medicaid benefits were authorized after the respondent denied the petitioner’s benefits due to the petitioner’s failure to meet the disability requirement. The petitioner’s representative asserted that the Social Security approved the petitioner’s disability. And the respondent determined that the petitioner’s ICP and Medicaid Program benefits would be authorized leaving no further issue to be determined by the hearing officer. Fla. Admin. Code, §65A-1.710- 10F-07368
The Department correctly denied the petitioner’s Medicaid benefits when the petitioner failed to meet the disability requirement. The reviewing nurse was unable to establish that the petitioner’s impairments would last longer than six months. And the evidence presented at the hearing did not establish that the petitioner’s condition worsened while being a patient in the nursing home nor was there a disabling condition that would last 12 months or longer. Therefore, the petitioner’s condition did not meet step two of the disability evaluation as required by the federal regulation. 20 C.F.R. § 416.905, Fla. Admin. Code 65A-1.710(2)- 11F-01496
The appeal is dismissed as not yet ripe for appeal because the Medicaid application did not list the petitioner as an interested party. Therefore, the Department did not take any action regarding the petitioner and the appeal was dismissed. Fla. Admin Code §65-2.044, 65-2.056- 11F-05388
The hearing officer granted a 500 dollar monthly increase in the community spouse’s allowance when the petitioner proved that the community spouse had additional unexpected medical expenses. Fla. Admin. Code at 65A-1.7141, 65A-1.716- 11F-03223
The denial of an increase in spousal allowance was upheld when the petitioner failed to present evidence of exceptional circumstances resulting in significant inadequacy of the allowance to meet the community spouse’s current needs. Fla. Admin. Code 65A-1.713 (1)(d)(4), 65A-1.7141 (1) 11F-02086
The denial of an increase in spousal diversion was upheld when the petitioner failed to prove that the community spouse’s expenses for home repair and appliances were exceptional circumstances that resulted in the community spouse’s needs not being met. Fla. Admin. Code at 65A-1.716(5)- 10F-06988
The denial of an increase in spousal diversion was upheld when the petitioner failed to prove that the patient responsibility and spousal diversion amount were incorrect. The spousal income of $4007.32 exceeded the adjusted shelter and utility expenses of $1471.84. And based on the Maintenance Need Allowance amount of $208.68, the patient responsibility (PR) amount of $1233.32 monthly was also correct. Fla. Admin. Code 65A-1.712, Fla. Admin. Code 65A-1.714- 11F-00832
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