Focus on Subspecialties: How to help Medicaid patients receive medically necessary services

You are asked to write a letter of medical necessity (LMN) for a patient covered by Medicaid who may need home care or therapeutic services initiated or sustained. These might include durable medical equipment, skilled nursing services, a personal care (home health) aide or other services by a licensed professional, such as applied behavior analysis.

How can you write the most influential letter on your patient’s behalf?

Regardless of how Medicaid is financed in your state, certain benefits are mandated under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program. This article details how you can leverage knowledge about EPSDT to fortify your LMN.

Covered services

The Medicaid Act lists 29 services that a state must or can cover for adults but are mandatory for children. The list includes a range of physician, hospital and outpatient medical care, respiratory care, rehabilitative services and other medical or remedial care recognized under state law or furnished by licensed practitioners within the scope of their practice under state law. It also includes durable medical equipment, prosthetics, private duty nursing services and personal care services.

These are all “covered Medicaid services” for the child, as long as they are deemed necessary tocorrect or ameliorate conditions discovered through screening services (which pediatricians perform routinely).

Pediatricians sometimes conflate private duty nursing and personal care services, but they are different. Private duty nursing services consist of skilled, sometimes complex care provided by licensed practical or registered nurses typically working eight- to 12-hour shifts, five or seven days per week. Personal care services, provided by personal care aides (also called home health aides), include help with activities of daily living like dressing, grooming, bathing and eating.

What to include in LMN

Jane Perkins, J.D., M.P.H., legal director of the National Health Law Program, and Douglas McNeal, M.D., FAAP, a member of the AAP Section on Home Care Executive Committee, presented a session at the 2015 National Conference & Exhibition titled “In-Home Pediatric Care: Children Need It, and the Law Requires It.” They recommend that an LMN be paired with a physician’s order on a prescription, practice letterhead, EPSDT screen form or other claim form. The letter should include the following:

• the patient’s diagnosis and prognosis, as best you can judge;
• the patient’s history with details of treatments and services, and the role(s) the parent or family caregiver(s) have played in providing those services;
• a detailed description of the services being requested, how they will help the child and length of time they will be needed; and
• language at the beginning or end of the LMN stating: “These services are being requested under the Medicaid EPSDT benefit to correct/ameliorate the physical/mental/developmental effects of my patient’s condition(s) and will assist my patient to achieve/maintain maximal functional capacity.”

If applicable, add that the requested service(s) is/are “reasonably expected to prevent the onset of” any specific secondary illness, condition or disability that you can foresee (e.g., worsened contractures, progressive lung disease).

“EPSDT-mandated services are a legal entitlement,” Perkins said, “just like a free and appropriate public education.”

Responding to denials

If medically necessary services are denied, advise or help your patient’s family (and patient, as able) to demand the denial in writing. This notice of denial should include the factual and legal basis for action and the family’s right to appeal the denial and continue to receive any benefits already in place at the same amount, duration and scope while the appeal is being heard.

In some states, the pediatrician can request a “peer-to-peer review” by a professional with a specialty background pertinent to your patient’s needs. Medicaid managed care plans may require that a grievance process be pursued first, but if the care is needed urgently, advise or help the family to request an expedited appeal.

If the Medicaid office claims the family should provide the care instead of a licensed professional, you may need to argue that the “medically necessary services requested exceed those that this family can or any family could reasonably provide,” Perkins said.

You also can refer the family to free legal services in the community, such as disability rights (protection and advocacy) services or, if available, a medical-legal partnership. (See resource.)

Dr. Okun is chair of the AAP Section on Home Care Executive Committee.