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Fair Hearing of the Month

Fair Hearing #7273600L (September 2, 2016)

December 2, 2016

Congratulations to Ashley Omudo-Dede, Nassau/Suffolk Law Services!

Managed Care Plan directed to replace wheelchair ramp that limited appellant's ability to leave home without three aides.

Appellant receives Medicaid through a managed long term care plan (“Plan”). Plan authorized the installation of a portable ramp at Appellant’s home. Appellant’s sister reported inadequacies with the installation, specifically the concrete path and requested a new concrete walkway. On May 5, 2016, the Plan issued a Final Determination denying the new wheelchair ramp.

Appellant weighed 275 pounds and a wheelchair carrying that weight could not negotiate the walkway. Three people were required to convey the Appellant down the stairs and wheel her to the street, depriving Appellant of social opportunities, and creating a safety concern in case of a fire. Her representative presented fh#7231991P, another hearing where the ALJ had held that the Plan's definition of medical necessity was too restrictive when the Appellant in that case was unable to leave the home for normal activities and was in danger when there was an emergency.

The Plan contended that "many people are unable to leave their homes," and that Appellant's medical needs were being fully met. The ALJ held that medical necessity included the need to correct or cure conditions that interfere with the capacity for normal activities or endanger life. The record supported the need to be able to leave the home for reasons other than medical appointments, and to ensure safety. The Managed Long Term Care Plan’s determination that the replacement ramp is not medically necessary was not correct and is reversed.


 

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