RE: Colorado update

December 30, 2002

's response to the exception(s) filed by Kaiser/Colorado Dept. of

Health Care Policy & Financing was uploaded a couple of days ago, and you

can download it from

medicaid/files/CO_Exception_response.PDF .

I encourage everyone to download and read this. It's a terrific brief. It's

important for everyone here to know and understand the law for the sake of

your child. If you take the time and read through the court decisions

posted here plus read the articles from the peer-reviewed medical journals

also posted here--you will know your stuff.

You can win any argument with any doctor and you can win any argument with

any Medicaid case workers and/or attorneys or judges. It is important to

know in detail the science and the law--and the doors will open.

I spent 45 minutes on the phone this morning with an attorney who's been

practicing Medicaid law for children for 14 years, but she's never bothered

to look up the specific language as it appears in the federal statute. She

did not believe me when I told her Paragraph 5 does not say " medically

necessary. " Finally she agreed to pacify me so I gave her the Internet

address for the EPSDT statute at 42 USC § 1396d®.

She almost died when she saw that I was right.

She then agreed to meet me in person this Friday morning at 11 am. She's

also my new state representative, and I'm taking Ed Nemeth's California

proposal that makes it illegal for a 3rd party payor to not reimburse HBOT

for a cp child.

Folks, the world is changing, and we are helping to change it. We can

change it a lot faster if we know our stuff. So learn this stuff. Yes

there's a lot of reading, and you might have to buy a medical

dictionary--but learning this " language " will bring a lot more benefits to

our children that going to Holland and trying to learn Dutch.

When we first began exploring the possibility of Medicaid reimbursement for

HBOT we had an extremely difficult time trying to find anyone within the

Georgia Department of Medical Assistance to have a sensible and reasonable

conversation about this.

In frustration, we went straight to the top and made our request directly

to the Medicaid Commissioner himself. I figured it would cut out some of

the bureaucracy--which it did--but it also kept our case front and center

with the commissioner.

What has done is absolutely brilliant. By staying under the radar

with a low profile, she's managed to take advantage of perhaps the state's

greatest vulnerability: it's own bureaucracy.

Neither the bureaucrats at Kaiser nor the bureaucrats at Colorado Medicaid

showed up for the hearing before the Administrative Law Judge. They dropped

the ball and lost their only chance to enter evidence into the case.

Even if the state/Kaiser appeals there still won''t be any evidence in the

record to support their position. The only evidence will be a 300-page

3-ring binder put together by a Mom who's kicking some kind of ass.

This is so great.

They cannot enter evidence--even if that idiot Nazi Collet were

to be their expert witness it doesn't matter--they cannot enter evidence.

will win.

Further, because Kaiser contracted with the state to provide Medicaid

services, this case can now (or soon will) be referenced for folks that

have Kaiser as a 3rd party payor.

Plus, Kaiser recently pulled out as the Medicaid administrator in Colorado

(perhaps because of this case?)--this means the responsibility for fighting

HBOT reimbursement now falls on the shoulders of the people least skilled,

least intellectually equipped, and least interested in fighting this

fight--the bureaucrats at Colorado Medicaid.

This has happened because had the courage and the fortitude to do

her homework and then do some asking.

This is so incredible. presented his own case. Praise God. This is

so great.

--if the case goes further, God will provide you with an attorney.

Don't worry about that.

2003 is our year.

>The fight continues here in Colorado.

>

>As a recap, we started HBOT in August of 2001 for my 20 year old son, who

>has severe spastic quadriplegia cerebral palsy. We have seen many

>improvements such as better vision or visual attention, less spasticity,

>and speech that is more readily understood by anyone. Unfortunately,

>because of our eagerness to start and his age (where he doesn't receive so

>many services or see so many doctors), we didn't have measurements to

>prove these assertions. As it is, we had asked his Kaiser rehab specialist

>to refer us to receive treatments, which he did and which Kaiser (as a

>Medicaid provider) denied to cover. We appealed, they denied, we appealed,

>they denied, and we appealed to the Administrative Law Judge and were

>granted a hearing that finally, after several postponements, took place on

>August 20th. We showed up with our 300 page binder ready to present our

>case. Kaiser never showed up. My son personally told the judge that we

>wanted to present our case, so that it would be entered into evidence and

>we proceeded to do so. I summarized the evidence in the binder, and asked

>2 witnesses to testify. One was the director of the center where he

>receives HBOT and the other was the wife of another patient, testifying to

>her husband's improvements after HBOT (he is a stroke victim of about 9

>years).

>

>Since Kaiser did not show up, the court ruled in our favor. Freels

>posted the ruling on the member's site at:

>medicaid/files/Decision_4_HBOT_CO_Medicaid\

..

>PDF

>

>Within 30 days, Kaiser and the Colorado Dept. of Health Care Policy &

>Financing both filed exceptions to the ruling. Kaiser stated that they had

>not been notified of the hearing, argued that coverage of HBOT is not part

>of Kaiser's Medicaid contract and submitted new evidence relating to the

>effectiveness of HBOT in treating CP. The Dept. of Health Care Policy.

>argued that HBOT must be denied because it is " experimental or

>investigational " and not " general accepted by the medical community " and

>that requests for EPSDT patients needed to be submitted with a Prior

>Authorization request (PAR). They also submitted " evidence " from the Duke

>Center for Hyperbaric that cerebral palsy is not an indicator for HBOT,

>etc.

>

>So..I spoke to a couple of lawyers and finally, the Colorado Legal

>Services agreed to respond to these exceptions on our behalf. They argued

>on several points. One is that since they didn't show up at the hearing,

>they lost their chance to offer evidence. So anything that they put in the

>exception as evidence has to be discarded. We, on the other hand, were

>able to include in our response the decision in Georgia that was reached

>in November (see Jimmy Freels decision at:

>medicaid/files/Georgia.Appeals.Court.PDF

).

>This was not new evidence being offered but case law to be pointed out,

>that they could not deny coverage under EPSDT based on the treatment being

>experimental/investigational. Our lawyers also argued about the submission

>of the PAR and the EPSDT wording, stating that any contact with a treating

>physician gives rise to the treatment mandate. And that Kaiser itself did

>not file the PAR. And that if Kaiser does not cover the treatment sought,

>then they are obliged to cover the therapy outside the contract. And that

>they were notified of the hearing so it was no excuse for not being there.

>

>Well, that's what the lawyers' said in layman's terms. Freels will

>be uploading the response in a day or two. And maybe it will make more

>sense when you read it yourself.

>

's response to the exception(s) filed by Kaiser/Colorado Dept. of

Health Care Policy & Financing was uploaded a couple of days ago, and you

can download it from

medicaid/files/CO_Exception_response.PDF

>

>When we first heard about HBOT, I did a lot of research. I spoke to people

>who had received treatment, I did research on the internet. I didn't go

>into it with the idea that insurance would cover it. I raised money and

>had lots of wonderful relatives (one in particular) and friends who wanted

>every opportunity for to reach his fullest potential. He has

>charmed many lives with his courage and his smile. But when we were given

>the opportunity to request that Kaiser pay for it, and had official

>denials, we decided to join others and get into the fight. Sometimes I

>have felt like giving up. If we raise more money and get more treatments,

>fine. It will help . But then I look at other families, with younger

>children, whose lives can be helped tremendously by the improvements HBOT

>can bring. And other alternative therapies. We have to think outside the

>box that the medical profession puts us in. It's almost too late for my

>son, because of his age and severity. I truly believe if HBOT had been

>discussed with me when he was a baby, we would have tried it and his brain

>injury would not have been so severe. But then again, we wouldn't have

>known how bad it could have been and how much we would have needed it.

>That's the trouble with brain injury. When they're babies, you don't

>always know how bad it's going to be until they don't develop. Anyway, I

>digress. Whether it is HBOT or other therapies mentioned on this list, we

>cannot let the medical profession put us aside. In 20 years, I have seen

>doctor after doctor treat strangely. I think since they cannot

> " cure " him, they just look at that little part that they are treating and

>not the whole person. As parents, we're the ones that look at the whole

>child, and want a whole treatment, cure, anything that will make it

>better.

>

>So we asked for services, filed the appeals, prepared the evidence (hours

>of research, compiling, copying), and faced the judge. The lawyer is not

>optimistic. He thinks that if it is remanded back to the court and Kaiser

>does show up, that we will lose. That there is not enough evidence to show

>HBOT should be covered. He says if it goes further, they cannot invest the

>resources in fighting something they don't think they'll win. So we'll

>seek out other lawyers. There's another firm that represents disabled

>people here in Colorado that is interested but didn't have time for the

>last response but may have time later. So there are other options if this

>goes further, either if it's remanded or appealed.

>

>And if we, here in Colorado, can progress with our fight, utilize the

>research and the court battles of others, then our fight and court battles

>can be used by even more of you. And we all win. For our kids.

>

December 31, 2002

,

Thanks for the update on things. As you know we will not give up either we are

waiting on the results of the 3rd appeal currently and will then go forward with

a law suit if necessary.

I just want to add to everyone we have met and while in Denver

doing hbot and you gus are wonderful. Meeting the people I have met has given

us more strength to go on with this fight.

Thanks and !!!!!! Collin sendshis love.

Hope and Prayers,

Dawn, Collin's mommie

<denise6179@...> wrote:The fight continues here in Colorado.

As a recap, we started HBOT in August of 2001 for my 20 year old son, who has

severe spastic quadriplegia cerebral palsy. We have seen many improvements such

as better vision or visual attention, less spasticity, and speech that is more

readily understood by anyone. Unfortunately, because of our eagerness to start

and his age (where he doesn't receive so many services or see so many doctors),

we didn't have measurements to prove these assertions. As it is, we had asked

his Kaiser rehab specialist to refer us to receive treatments, which he did and

which Kaiser (as a Medicaid provider) denied to cover. We appealed, they denied,

we appealed, they denied, and we appealed to the Administrative Law Judge and

were granted a hearing that finally, after several postponements, took place on

August 20th. We showed up with our 300 page binder ready to present our case.

Kaiser never showed up. My son personally told the judge that we wanted to

present our case, so that it would be entered into evidence and we proceeded to

do so. I summarized the evidence in the binder, and asked 2 witnesses to

testify. One was the director of the center where he receives HBOT and the other

was the wife of another patient, testifying to her husband's improvements after

HBOT (he is a stroke victim of about 9 years).

Since Kaiser did not show up, the court ruled in our favor. Freels posted

the ruling on the member's site at:

medicaid/files/Decision_4_HBOT_CO_Medicaid.\

PDF

Within 30 days, Kaiser and the Colorado Dept. of Health Care Policy & Financing

both filed exceptions to the ruling. Kaiser stated that they had not been

notified of the hearing, argued that coverage of HBOT is not part of Kaiser's

Medicaid contract and submitted new evidence relating to the effectiveness of

HBOT in treating CP. The Dept. of Health Care Policy. argued that HBOT must be

denied because it is " experimental or investigational " and not " general accepted

by the medical community " and that requests for EPSDT patients needed to be

submitted with a Prior Authorization request (PAR). They also submitted

" evidence " from the Duke Center for Hyperbaric that cerebral palsy is not an

indicator for HBOT, etc.

So..I spoke to a couple of lawyers and finally, the Colorado Legal Services

agreed to respond to these exceptions on our behalf. They argued on several

points. One is that since they didn't show up at the hearing, they lost their

chance to offer evidence. So anything that they put in the exception as evidence

has to be discarded. We, on the other hand, were able to include in our response

the decision in Georgia that was reached in November (see Jimmy Freels decision

at:

medicaid/files/Georgia.Appeals.Court.PDF ).

This was not new evidence being offered but case law to be pointed out, that

they could not deny coverage under EPSDT based on the treatment being

experimental/investigational. Our lawyers also argued about the submission of

the PAR and the EPSDT wording, stating that any contact with a treating

physician gives rise to the treatment mandate. And that Kaiser itself did not

file the PAR. And that if Kaiser does not cover the treatment sought, then they

are obliged to cover the therapy outside the contract. And that they were

notified of the hearing so it was no excuse for not being there.

Well, that's what the lawyers' said in layman's terms. Freels will be

uploading the response in a day or two. And maybe it will make more sense when

you read it yourself.

When we first heard about HBOT, I did a lot of research. I spoke to people who

had received treatment, I did research on the internet. I didn't go into it with

the idea that insurance would cover it. I raised money and had lots of wonderful

relatives (one in particular) and friends who wanted every opportunity for

to reach his fullest potential. He has charmed many lives with his

courage and his smile. But when we were given the opportunity to request that

Kaiser pay for it, and had official denials, we decided to join others and get

into the fight. Sometimes I have felt like giving up. If we raise more money and

get more treatments, fine. It will help . But then I look at other

families, with younger children, whose lives can be helped tremendously by the

improvements HBOT can bring. And other alternative therapies. We have to think

outside the box that the medical profession puts us in. It's almost too late for

my son, because of his age and severity. I truly believe if HBOT had been

discussed with me when he was a baby, we would have tried it and his brain

injury would not have been so severe. But then again, we wouldn't have known how

bad it could have been and how much we would have needed it. That's the trouble

with brain injury. When they're babies, you don't always know how bad it's going

to be until they don't develop. Anyway, I digress. Whether it is HBOT or other

therapies mentioned on this list, we cannot let the medical profession put us

aside. In 20 years, I have seen doctor after doctor treat strangely. I

think since they cannot " cure " him, they just look at that little part that they

are treating and not the whole person. As parents, we're the ones that look at

the whole child, and want a whole treatment, cure, anything that will make it

better.

So we asked for services, filed the appeals, prepared the evidence (hours of

research, compiling, copying), and faced the judge. The lawyer is not

optimistic. He thinks that if it is remanded back to the court and Kaiser does

show up, that we will lose. That there is not enough evidence to show HBOT

should be covered. He says if it goes further, they cannot invest the resources

in fighting something they don't think they'll win. So we'll seek out other

lawyers. There's another firm that represents disabled people here in Colorado

that is interested but didn't have time for the last response but may have time

later. So there are other options if this goes further, either if it's remanded

or appealed.

And if we, here in Colorado, can progress with our fight, utilize the research

and the court battles of others, then our fight and court battles can be used by

even more of you. And we all win. For our kids.

December 31, 2002

- For some reason I can not get on the site to download the new info ( I

think my office set up some new blocks for the new year). Could someone forward

it to me as an attachment? Thank you.

Amy Young

Program Manager

Lowell Public Schools

Office of Extended Time Programs

(978) 970-5419

Re: [ ] Colorado update