DHHS reverses denial, agrees to cover cough-assist machine for child with multiple disabilities

January 2006

The Department of Health and Human Services has reversed its decision denying Medicaid payment for a cough-assist machine for Bryant P. Bryant, a 16 year old boy who has multiple disabilities, has significant muscle weakness and is too weak to cough well enough to remove respiratory secretions from his airway. The machine is medically necessary to prevent airway obstructions, lung collapse, and pneumonia. Bryant has frequent hospitalizations, many of which are related to his respiratory difficulties.

DHHS originally denied Bryant’s request for a cough-assist machine in December 2004, despite the strong recommendations of three physicians that the machine was medically necessary. DHHS again denied the request after additional evidence was submitted supporting Bryant’s claim. DHHS refused to reverse its decision until after a hearing in January 2006, when it appeared that it would lose the appeal.

This case is another instance in which a Medicaid recipient was denied services despite substantial evidence of medical necessity. In this case and others, the recipient had to go through a protracted and difficult process of reconsideration and appeal of the denial. Only after a full hearing, but prior to the issuance of an administrative decision, when it appeared that DHHS would lose the appeal, did DHHS reverse itself. The DRC is concerned that other Medicaid recipients are being denied medically necessary services because of the lack of resources or stamina to appeal such denials and the inability to stay the course through a complicated and often expensive hearing process.

 

updated July 20, 2017