Opinion ID: 2653500
Heading Depth: 3
Heading Rank: 1

Heading: The variance will otherwise meet the goals of the Choices for Care waiver; and

Text: 2. The variance is necessary to protect or maintain the health, safety or welfare of the individual. The need for a variance must be documented and the documentation presented at the time of the variance request. Id . § XI (A). Even assuming that the second prong of this test is functionally equivalent to a determination of medical necessity, the fact that the regulation, on its face, gives DAIL discretion as to whether to grant a variance undermines DCF’s claim that a denial of services is, as a matter of law, tantamount to a finding of no medical necessity. ¶ 31. Moreover, the records in these consolidated cases do not support—and in the McCool case actually contradict—DCF’s assertion that DAIL concluded that the additional services were not medically necessary. At the patient-share hearings before the hearing officer, both petitioners attempted to demonstrate through witness testimony and 288B forms from treating physicians that the requested additional personal care services were medically necessary. The hearing officer at times limited such evidence under the assumption that our decision in Brett precluded deductions from patient shares for services that could be covered by Choices. Nevertheless, Brett provided testimony from her Choices case manager, her caregiver daughter, and her treating nurse practitioner describing her medical condition and detailing the time necessary to assist her in each of the ADLs. ¶ 32. For its part, DCF presented the testimony of DAIL’s long-term clinical coordinator to explain the basis for denying Brett’s request for additional personal care services. Although she stated her opinion that Brett was receiving all medically necessary services under the Choices program, she acknowledged that she conducted her assessment based solely on a “paper review” of the case manager’s submission and that her denial of the additional requested coverage was based on the lack of any functional change in Brett’s condition since the last annual review. She explained that there were maximum amounts of time set for each ADL or IADL under CFC Regulations § VIII, and that additional time beyond those maximums is generally granted under the variance procedure only if there has been changes in the beneficiary’s condition since the most recent assessment. ¶ 33. The case manager testified that the DAIL coordinator had told her that she could not justify the additional hours because the case manager’s comments as to each of the ADLs did not show a change in Brett’s condition. According to the case manager, she concurred that Brett’s condition had not recently deteriorated significantly, but she explained to the DAIL coordinator that Brett was seeking coverage for additional medically necessary third-party personal care services because her expenses for those services, which had previously been provided by her daughter on weekends, were no longer being deducted from Brett’s patient share obligation. The DAIL coordinator acknowledged having this discussion with Brett’s case manager, but nonetheless denied the additional hours based on there being no significant change in Brett’s medical condition. In its decision, the Board did not address the medical necessity of the requested additional personal care services, but rather ruled that “ noncovered ” meant “non-coverable” under Brett and that Brett had failed to appeal DAIL’s determination of her needs. ¶ 34. Nothing in this record supports the assertion that DAIL concluded that the services were not medically necessary; its determination turned on the lack of sufficient deterioration in Brett’s condition since its prior assessment to warrant additional personal care services without consideration of the fact that the “additional” services had been provided all along by Brett’s daughter. Nor did the Board make a finding on the medical necessity of the services initially requested by Brett from DAIL, for which she subsequently sought a deduction in the calculation of her patient share. ¶ 35. Similarly, at McCool’s patient-share hearing, a DAIL representative testified that McCool could resubmit a request for additional hours under the variance procedure if she could show a “significant functional decline” from the last assessment. When McCool’s attorney attempted to pursue further the process underlying a reassessment review and variance procedure, the hearing officer stated that the case was really about whether McCool met the requirements for general supervision and that this was not the forum “to have a determination of whether the original calculation by DAIL was accurate or not because there are separate appeal rights from that that could have been taken at the time.” Nevertheless, McCool was able to present the testimony of her treating physician, her caregiver son, and her case manager. Those witnesses testified about the significant deterioration of McCool’s medical condition, and the son expressed frustration at DCF’s decision to no longer allow a deduction for additional personal care services provided by him. After making numerous findings regarding McCool’s significant needs, the Board concluded that the evidence did not support a finding that McCool needed general supervision services, but that the evidence did support “the need for additional time for ADLs.” The Board asserted that her “case is compelling” and “her need for care is evident” but concluded that she was “seek[ ing ] redress through the wrong mechanism.” ¶ 36. The record in McCool’s hearing not only fails to support DCF’s position that the requested services were not medically necessary; it flatly contradicts that position. The Board made an express finding that the evidence supported the need for additional time for ADLs. It did not specify how many additional hours of ADLs were medically necessary. ¶ 37. Accordingly, we reverse the Board’s orders in each of the consolidated cases and remand the cases to the Board. In Brett’s case, the Board should determine whether the additional personal care services for which petitioners sought a deduction were medically necessary, and, if so, how many additional hours of personal service care were medically necessary. Brett is entitled to deductions from her patient share for the reasonable additional personal care expenses to the extent they were medically necessary. In McCool’s case, the Board has already found that additional services for ADLs were warranted; it should determine the number of additional hours and calculate McCool’s patient share accordingly. [1]