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Staged procedures may be covered by Medicaid where shown to be medically necessary.

Topic: Medicaid Eligibility, Decided by Judge Malihi 
Docket Number: 1737794 , Decision Date: 2017-08-25 
Attachment: Click here to download the decision. 

DCH erred by denying prior Medicaid authorization for a bilateral nipple/areola reconstruction and nipple tattooing procedure incident to bilateral breast reduction surgery, the fact that both procedures were not performed simultaneously notwithstanding, where the surgeon seeking Medicaid coverage for the procedure proved, through his own [..] Read More..

Hospice services sufficient evidence that child met institutional level of care criteria

Topic: Medicaid Eligibility, Decided by Judge Woodard 
Docket Number: ******* , Decision Date: 2017-02-08 
Attachment: Click here to download the decision. 

Evidence that a child born with a terminal condition received hospice services from a skilled professional at home during the one month he was alive was sufficient to show that he received skilled nursing services of the requisite amount and duration for him to qualify [..] Read More..

Transfer penalty inappropriate because real property was sold for current market value.

Topic: Medicaid Eligibility, Decided by Judge Malihi 
Docket Number: ******* , Decision Date: 2017-01-10 
Attachment: Click here to download the decision. 

A nursing home resident proved that his property was worth significantly less than was alleged by the Division of Family and Children Services by submitting the affidavit of a realtor and a retroactive broker’s price opinion.  Therefore, DFCS’s assessment of a transfer of assets penalty [..] Read More..

Receipt of Emergency Medicaid requires proof of Georgia residency.

Topic: Medicaid Eligibility, Decided by Judge Baxter 
Docket Number: ******* , Decision Date: 2016-06-08 
Attachment: Click here to download the decision. 

A citizen of Belize who was flown into Georgia to receive treatment after a butane tank explosion in Belize was not entitled to Emergency Medicaid because he did not establish Georgia residency.

Where a valid court order of support exists, Respondent must increase a nursing home community spouse’s monthly income allowance by the amount of the ordered support.

Topic: Medicaid Eligibility, Decided by Judge Schroer 
Docket Number: ******* , Decision Date: 2017-03-13 
Attachment: Click here to download the decision. 

When determining the amount a nursing home resident must pay each month toward the costs of care in a nursing facility, if the resident has a community spouse and a valid court order of support against the resident exists, DFCS must first deduct the amount [..] Read More..

The agency failed to support its position that blindness/hearing loss were not functional impairments.

Topic: Medicaid Eligibility, Decided by Judge Malihi 
Docket Number: ******* , Decision Date: 2017-06-08 
Attachment: Click here to download the decision. 

The Department of Community Health failed to support its argument that a SOURCE beneficiary could not show that she met the level of care requirements through evidence of blindness and partial hearing loss because such deficits did not constitute “functional impairments” covered by the Program.

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