U.S. DEPARTMENT OF LABOR OFFICE OF WORKERS' COMPENSATION PROGRAMS
DIVISION OF ENERGY EMPLOYEES OCCUPATIONAL
ILLNESS COMPENSATION
FINAL ADJUDICATION BRANCH
 DOL Seal


NOTICE OF FINAL DECISION

This is the decision of the Final Adjudication Branch (FAB) concerning your request for home health care services under Part E of the Energy Employees Occupational Illness Compensation Program Act of 2000, as amended (EEOICPA), 42 U.S.C. § 7384 et seq. For the reasons set forth below, your request for four hours per day of a Home Health Aide (HHA) and four hours a month of Targeted Case Management (TCM) under Part E of EEOICPA for the period of October 10, 2016 through August 6, 2017 is denied.

STATEMENT OF THE CASE

On July 27, 2011, FAB issued a final decision approving your claim for hearing loss under Part E. As part of that decision, FAB awarded you medical benefits for the care and treatment of this covered illness.

On October 21, 2016, you requested home health care services because of the effects of your hearing loss. In support of your request, you submitted a Letter of Medical Necessity (LMN) from your treating physician, Dr. Christopher L. Sperry, in which Dr. Sperry wrote that he had been your physician since August 10, 2016 and that he was ordering four hours per day of a HHA and four hours a month of TCM for October 10, 2016 through August 6, 2017. In addition, Dr. Sperry explained that the justification for these home health care services was the need to maintain a consistent environment, to reduce elements of surprise, to reduce disruptions, to reduce fall hazards, and to monitor and manage your hearing loss.

On January 30, 2017, the district office, via an informal letter decision, denied your request for home health care services. In that letter, the district office determined that Dr. Sperry had not provided sufficient explanation as to how your hearing loss was hampering your activities of daily living to the point of requiring assistance in the home by a HHA. Upon receipt of this informal decision, you asked for a formal recommended decision on your request in a letter dated February 21, 2017.

In response to your request, the district office reevaluated the matter and decided to refer your request to a DEEOIC nurse consultant to assess whether there was a medically indicated basis to justify the requested level of home health care services. In a March 24, 2017 response, the nurse consultant wrote:

Dr. Sperry opined daily HHA services were necessary “to provide a consistent physical environment and daily routine to reduce elements of surprise, overstimulation and confusion; to assist with daily auditory tasks [and] promoting communication that enhances the patient’s sense of dignity.” Medical records do not indicate how/why the claimant is unable to maintain “a consistent physical environment” related to his hearing loss. Sensorineural hearing loss in no way affects the claimant’s ability to maintain his home environment. Nor does Dr. Sperry explain how the HHA will “maintain a consistent environment.” Medical records also do not indicate if the claimant has been tested for potential use of hearing aids; if the claimant currently utilizes hearing aids; and/or the claimant’s hearing ability with use of hearing aids. Medical records do not indicate the claimant has any physical mobility or cognitive limitations preventing him from being able to access assistive services outside of his home. Medical records simply do not establish a reasonable medical rationale indicating a need for in-home healthcare services.

The district office then issued letters to you and your physician on several occasions asking for additional medical evidence to support your need for home health care services as they relate to your covered illness of hearing loss. No response to these development efforts was received by the district office.

Therefore, the district office issued an April 17, 2017 recommended decision to deny your request for home health care services for the period for October 10, 2016 through August 6, 2017 related to your covered illness of hearing loss under Part E of EEOICPA. In its recommendation, the district office explained its reasoning why it was denying your request, which included referring to the opinion of the nurse consultant, the lack of any discussion by your doctor as to the effect of hearing loss on your ability to perform activities of daily living, and lack of response from your physician to development requests.

Based on a review of the evidence in the case file, I hereby make the following:

FINDINGS OF FACT

1. On July 27, 2011, FAB issued a final decision accepting your claim for hearing loss under Part E of EEOICPA.

2. You requested home health care services for four hours per day of a HHA and four hours a month of TCM for the period October 10, 2016 through August 6, 2017.

Based on a review of the aforementioned facts, I also hereby make the following:

CONCLUSIONS OF LAW

Section 30.310(a) of the program’s regulations provides that “Within 60 days from the date the recommended decision is issued, the claimant must state, in writing, whether he or she objects to any of the findings of fact and/or conclusions of law contained in such decision. . .and whether a hearing is desired.” 20 C.F.R. § 30.310(a). You did not file any objections to the recommended decision within the 60 days allowed.

Covered employees are entitled to receive medical benefits under 42 U.S.C. § 7384t for their covered illnesses accepted under Part E. 42 U.S.C. § 7385s-8. These medical benefits can include 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 that illness. 42 U.S.C. § 7384t.

In assessing a request for home health care services, the Federal (EEOICPA) Procedure Manual Chapter 30.2g(2) explains the evidence that is required to establish that the services sought are medically appropriate:

(2) Level of care required. The doctor’s LMN must specify the appropriate type of health care professional who will attend to the patient, i.e., Registered Nurse (RN), Licensed Practical Nurse (LPN), PCA, Certified Nursing Assistant (CNA), or Home Health Aide (HHA). Generally, approved in-home skilled nursing services (RN/LPN) include services such as administration of prescription medication, wound dressing changes, administration of intravenous medications, assessment of patient’s medical condition, and communication with treating physician(s) regarding changes in accepted condition(s). Services provided by non-skilled persons such as home health aides or personal care attendants are typically intended for assistance with activities of daily living which often include mobility within the household, dressing and undressing, toileting, bathing, and meal preparation.

You are requesting home health care services based on your accepted covered illness of hearing loss. Your treating physician states that you need these services to maintain a consistent environment, to reduce elements of surprise, to reduce disruptions, to reduce fall hazards, and to monitor and manage your covered condition. However, your physician does not explain what the specific medical limitations are that are due to your hearing loss and are serious enough to warrant assistance from a HHA. As stipulated in the Procedure Manual, a HHA can assist with activities of daily living that you cannot perform due to your accepted illness. However, none of the prescribed services relate to what one would reasonably consider activities of daily living. Moreover, the services suggested for you are vague and undefined. For example, it is not clear what your physician means by “maintaining a consistent environment” or how a HHA is to “monitor and manage your covered condition.” I also conclude that there is no indication from your physician that your condition renders you incapacitated to a degree that precludes you from performing the recommendations of your physician such as avoiding fall hazards or disruptions. A nurse consultant who reviewed your case validated the defects that exist in your claim by opining that the medical rationale from your physician did not support your request.

The district office provided you multiple opportunities to submit medical evidence in support of your request. I have reviewed the evidence carefully and I see no response from you or your physician to the concerns raised by the district office. For this reason, I feel that no other medical assessment or evaluation of your request is appropriate. I also conclude that the recommended decision explains the deficiencies that exist with regard to the medical necessity of your requested home health care services, and that you have not provided the evidence necessary to overcome those problems.

I therefore finalize the recommendation to deny your request for four hours per day of a HHA and four hours a month of TCM under Part E of EEOICPA for the period of October 10, 2016 through August 6, 2017, and your request is hereby denied.

Washington, DC

Susan G. Price

Hearing Representative

Final Adjudication Branch