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Medical Necessity to Remove Allergens in Home to Abate Asthma Triggers

My mom has Microscopic PolyAngiitis, Asthma, and a number of other chronic progressive conditions. She is nearly 90 yo. She is in a Medicaid Program called MLTSS (Managed Long Term Services and Supports) and receives "nursing facility level of care at home." Her Chief Pulmonologist also manages her Asthma. One of the services covered by her HMO is called "Chore Services," includes "Deep Cleaning" of her apartment every 3 months. The HMO now claims "there is no medical necessity for 'deep cleaning' of her apartment to continue," and we reject that decision because we know how important it is to abate all elements that can cause infections, as well as the allergens and contaminants that trigger Asthma attacks. My mom's specialists and our family are frustrated the HMO does not see the medical necessity for continuing "Deep Cleaning" of her home, to prevent other infections from harming or killing her and I thought I would reach out to you for guidance.  Your thoughts and advice are greatly appreciated, as is your time and consideration on my mom's behalf.

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  • Melissa G

    Hi JJA! Welome to AAFA, so glad that you found us! 

    That is quite frustrating! Have you gotten a denial in a letter or has it been a verbal denial? Are you able to get the denial to go to a medical review board? Have the doctors written letters of medical necessity?

    You can also get a case manager with your insurance to help. 

  • JJA

    Thanks for your kind support, Melissa.

    Answers to your points below:

    Melissa: That is quite frustrating!

    JJA: We're past the point of frustration.  It is becoming exasperating.

    Melissa: Have you gotten a denial in a letter or has it been a verbal denial?

    JJA: First, Received Verbal Denial and Second, Received Letter of Denial

    Melissa: Are you able to get the denial to go to a medical review board?

    JJA: We just finished appealing the Letter of Denial via Stage 1 Appeal, and that was denied, as well.  We're preparing Stage 2 Appeal, which goes to the HMO's Medical Review Board.

    Melissa: Have the doctors written letters of medical necessity?

    JJA: Yes and No.  All of my mom's specialists (PCP, Pulmonologist, Immunologist, Nephrologist, Cardiologist, Endocrinologist, Infectious Disease Specialist), all have individually and collectively signed Certification Letters confirming Medical Necessity for my Mom, based on her chronic, progressive, and incurable conditions — in relation to all other services provided, as part of her program.  Now, they will do another specific Medical Necessity Letter, in relation to this particular "Deep Cleaning" service and we will submit to the HMO's Medical Review Board.  Unfortunately, the way the HMO is behaving is that instead of accepting the same certifications from her doctors to apply, for example, to asking for a tissue + a cough drop + a glass of water + an asthma inhaler, etc., they are now asking for a separate letter certifying the medical need for each one — separately.

    Melissa: You can also get a case manager with your insurance to help. 

    JJA:  Unfortunately, her Case Manager, by state contract, is an employee of the HMO and although sympathetic to my mom and understanding of the medical necessity for these services, no employee wants to risk losing her job in order to be supportive of a patient,

    I'm not giving up, though, as I have learned quite a bit taking care of my mom for the past 5 years and after working with all her doctors since 2013, I have gained a very clear understanding of what doctors understand is required to care for patients with my mom's conditions.  Am sure the HMO understands this too; however, I have found that their decisions is influenced more by finances than by medical necessity; and, it's sort of a "game" for them to see if they make you run in circles, hoping you give up; but, when it comes to my mom, I'll run all the circles I have to so I can get her the help she requires and although I may get a bit tired, I won't give up, as long as there's another human being in need and I can help in some way.

    Thanks, Melissa.

    JJA.

  • Melissa G

    You are a great son JJA! The next step I would take is to call the insurance commissioner for your state and your governor. We had to do this earlier this year when our insurance denied a medication my daughter had been taking. It was approved within 48 hours. 

  • JJA

    Thanks again, Melissa.  Whatever I may do as her son pales by comparison with what she has done for me and countless fellow-beings since she was the age of 9 and worked to support her family.  I've reached out to the state's Medicaid Director, who manages a $17 BILLION budget and their quality monitoring unit is investigating the case, as they do not understand why all the obstacles from the HMO.  Next, is the Insurance and Banking Commission that regulates them, and ultimately the Governor's Office — not to mention taking this to the press, as that particular step seems to bring the focus right on top of the "culprits."  Hoping, the HMO will yield sooner rather than later, for my mom's sake.

  • LK

    Welcome, JJA!  I don't have any advice to give you but you are to be commended for your continued persistence to have the best care possible for your mother.  I pray  you and your mother's doctors are able to get the insurance company to keep doing the deep cleaning.

    Your mother sounds like one in a million.  Someone my father would call the "salt of the Earth."  

    My parents are in their late 80s and at this time are in fairly good health but I know there may be a time soon when I will need to start helping them more.  You are an inspiration.  Thank you.

  • JJA

    Lisa, your comments are humbling and I bow to you with much appreciation.  My mom is, indeed, one in a million, not just to me and to her family, but to everyone who has come in contact with her…totally selfless and always willing to sacrifice herself for others' sake…even at her own detriment.  When we were kids, around the age of 9, I remember food was scarce and when we came across one (1) steak, I remember, as if it were yesterday, that my mom would cut the steak into three pieces: one for my sister, one for me, and one for my dad.  She would just eat the fat herself.  Even at the age of 9, I wondered what would cause one human being to make that kind of sacrifice for others (even if their own family)?  That impressed me and it was my very first lesson in charity and selflessness.  How could anyone not be influenced by that modeling?  In fact, it influenced me so much that I spent many years of my career doing charitable work, raising millions of dollars, and helping many underserved communities, much in the same manner I am now helping my mom.  When she goes, I will have nothing to count on for myself, as I had to forfeit everything five years ago so I could move in with her and avoid her institutionalization which we all agreed was not an appropriate way to take care of her and less for someone to close the last chapters of her life without enjoying the recognition that now, for a change, someone would take care of her.  It's a mission I consider a privilege — not a burden — and although it is human when I get physically tired (or very irate about the behavior of her HMO, which is nothing but unjustified, selfish, and cruel), I am fueled by the desire to make things right and make sure she is taken care of, as she is most deserving to be.  There may be no cure for her condition, which is rare and strikes 1 in 1 million people (see vasculitisfoundation.org) but, that said, you better believe am going to make sure that she remains stable, peaceful, and happy until she decides to go.  That, in itself, Lisa, will make me the richest man alive and I will live the rest of my own years with my head held high, knowing I did my very best.  If only my mom's HMO behaved accordingly… Thanks again, Lisa, for your kind words.  JJA.

  • LK

    JJA,  Your mother knew the true meaning of Love.  As it says in 1 Corinthians 13 - 

    " 4 Love suffers long and is kind; . . . " and " bears all things, believes all things, hopes all things, endures all things."  NKJV

    You are wise in saying that doing this for your mother "will make me the richest man alive and I will live the rest of my own years with my head held high, knowing I did my very best."    She raised a true gentleman.

  • K8sMom2002

    JJA, hugs on the obstacles you're facing! It sounds as though you are doing all the right things, and I hope the seeds you've planted will bear good fruit!

    A few other suggestions:

    • Do you have data about how many hospitalizations she had BEFORE the deep cleaning began and AFTER the deep cleaning began? Perhaps if you can show that it saves money in the long run, that will help.
    • Could you reach out to your state representative or senator? And possibly your US Representative?

    Medicaid is a different sort of animal. It is regulated at the state level, as the dollars that pays for it flow into the state in a block grant — a big pot of money that the state gets to decide how they spend it.

    However, there are federal regulations and policy as well. You might check with the to see if a federal policy change may be part of this. Your US Representative's constituent services staff can help you do this.

    In addition, you may have already reached out to your state's . These programs provide free one-on-one insurance counseling and assistance to Medicare beneficiaries, their families, friends and caregivers.

  • JJA
    LK posted:

    JJA,  Your mother knew the true meaning of Love.  As it says in 1 Corinthians 13 - 

    " 4 Love suffers long and is kind; . . . " and " bears all things, believes all things, hopes all things, endures all things."  NKJV

    You are wise in saying that doing this for your mother "will make me the richest man alive and I will live the rest of my own years with my head held high, knowing I did my very best."    She raised a true gentleman.

    Lisa, I appreciate your kind words and your time to share them with me.  On my Mom's behalf, I thank you.

  • JJA
    K8sMom2002 posted:

    JJA, hugs on the obstacles you're facing! It sounds as though you are doing all the right things, and I hope the seeds you've planted will bear good fruit!

    A few other suggestions:

    • Do you have data about how many hospitalizations she had BEFORE the deep cleaning began and AFTER the deep cleaning began? Perhaps if you can show that it saves money in the long run, that will help.
    • Could you reach out to your state representative or senator? And possibly your US Representative?

    Medicaid is a different sort of animal. It is regulated at the state level, as the dollars that pays for it flow into the state in a block grant — a big pot of money that the state gets to decide how they spend it.

    However, there are federal regulations and policy as well. You might check with the to see if a federal policy change may be part of this. Your US Representative's constituent services staff can help you do this.

    In addition, you may have already reached out to your state's . These programs provide free one-on-one insurance counseling and assistance to Medicare beneficiaries, their families, friends and caregivers.

    Cynthia, each and every one of your suggestions is absolutely great and I will follow up accordingly.  Thanks so very much for taking the time and providing so many links to so many valuable resources.  To quote your own words: "if the seeds I've planted will bear good fruit…" your suggestions just gave them "great plant food."  Thanks, am very grateful.

  • K8sMom2002

    Here's hoping it won't take long for you to see some good answers and a way to help your mom get the care she needs!

  • Melissa G

    @JJA How is everything going with trying to get the deep cleaning approved? How is your mom doing? How are you holding up?