Sample Recommended Decision to Deny Home Health Care

 

EMPLOYEE:                John Doe

FILE NUMBER:            123-00-4567

 

NOTICE OF RECOMMENDED DECISION

(MEDICAL BENEFITS ONLY)

 

This is the Recommended Decision of the [applicable district office] District Office regarding the request for in-home medical services filed by you under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA or the Act).  The [appropriate] District Office recommends the request be denied for the reasons set forth below.

 

STATEMENT OF THE CASE

 

You filed a claim on (Insert Date), seeking benefits under the Act. On (Insert Date) the Final Adjudication Branch issued a final decision accepting the claim and awarding medical benefits for the condition of lung cancer.

 

On (Insert Date) the (appropriate) District Office received a request for in-home skilled nursing care. The level of care and/or type of service to be provided was specified in a (Plan of Care or doctor’s letter – fill in the blank), dated (Insert Date).

 

Upon review and consideration of the request for in-home skilled nursing services it was determined that there is insufficient medical evidence to support that the nursing care services are required for the treatment of your accepted conditions. [This paragraph is only to be used if that is the reason for the denial.  Other reasons may include that the weight of medical evidence is with the DMC or second opinion, lack of any medical evidence. The decision should specifically discuss the medical evidence in the case file related to the issue.] On (Insert Date) the district office claims examiner (CE) sent a letter to you with a copy to your physician, requesting detailed information regarding the type and level of care required for the accepted condition(s).  Your doctor did not respond to this letter. On (Insert Date), the CE called Dr. (Insert Name)’s office to confirm that he received the (Insert Date) letter, and the CE questioned the doctor regarding the level of care you required. By follow-up letter dated (Insert Date) you were requested to provide the needed medical evidence.  As of this date, we have not received medical evidence sufficient to establish that the request for in-home health care services is required as a result of your accepted condition under the EEOICPA.

 

FINDINGS OF FACT

 

1.   You filed a claim under the EEOICPA on (Insert Date).

2.   On (Insert Date), the FAB issued a decision awarding you compensation in the amount of (Fill in amount) and medical benefits for the treatment of your [accepted condition].

3.   On (Insert Date), the district office received a request for in-home medical care.

 

CONCLUSIONS OF LAW

 

You do qualify as an “individual with cancer” [if applicable] as defined in 42 U.S.C. § 7384l (9) (B) (or Insert Appropriate Illness and Statutory Citation.)

 

42 U.S.C. § 7384t states that The United States shall furnish, to an individual receiving medical benefits under this section for an illness, the services, appliances, and supplies prescribed or recommended by a qualified physician for that illness which the President considers likely to cure, give relief, or reduce the degree or the period of the illness;

and

 

20 CFR Part 30 § 30.403 states that OWCP will authorize payment for personal care services under section 7384t of the Act, whether or not such care includes medical services, as long as the personal care services have been determined to be medically necessary and are provided by a home health aide, licensed practical nurse, or similarly trained individual.  The Office of Workers Compensation Programs (OWCP) will make the determination if personal care services are or are not medically necessary.

 

Sufficient medical evidence, necessary to make a determination as to the type of services and/or the level of care to be provided, has not been forthcoming from your treating doctor. Without this medical evidence, your request for in-home medical care cannot be granted. Therefore, the claim for in-home medical services is denied.

 

{Note: Depending upon the circumstances, the language in this sample decision can be modified for use in reducing or limiting services currently being provided, or in denying new requests for in-home care.  The usual cover letter for recommended denials should be used, which outlines the claimant’s rights following such a decision.)


Prepared by:

 

_____________________                     _____________

(Name)                                    Date

Claims Examiner

 

 

Reviewed and Certified by:

 

______________________                    _____________

(Name)                                   Date

Senior Claims Examiner