The Medicaid law for children (the EPSDT statute: EPSDT stands for Early,Periodic, Screening, Diagnostic, and Treatment services), is found at 42 USC § 1396d(r).

It can be found on the internet at: http://caselaw.lp.findlaw.com/casecode/uscodes/42/chapters/7/subchapters/xix/sections/section%5F1396d.html When you get there and the page has finished loading, do a "find" (hold down your control key and then press the letter 'F') then enter the word "ameliorate" (without the quotation marks), and it will take you to the body of Paragraph 5 of the EPSDT statute. You can then back it up to get the first 4 paragraphs as well. Paragraph 5 is the part you're most interested in for Hyperbaric Oxygen Therapy.

http://caselaw.lp.findlaw.com/casecode/uscodes/42/chapters/7/subchapters/xix/sections/section%5F1396d.html I've heard back from about 20 states so far and most are saying they will reimburse under Paragraph 5.

The Missouri, North Carolina, Virginia, and West Virginia Medicaid plans all reimburse Hyperbaric Oxygen Therapy for brain-injury. In addition, once they've been reminded of Paragraph 5 of the EPSDT statute as found in 42 USC § 1396d(r), Arkansas, Arizona, California, Hawaii, Kansas, Maine, Maryland, Michigan, Minnesota, Nevada, New York, Wisconsin, and Wyoming have all indicated they could reimburse HBOT should a Medicaid recipient in their states request it.

So far only Georgia and Louisiana have said they flat out won't reimburse.

The parents need to start requesting it. They can use the MUMS Hyperbaric Oxygen Therapy information packet as the resource from which to base their request.

The Texas Medicaid medical director is Dr. Beverly Koop (no relation to C. Everett), and we have had three or four extensive conversations about Hyperbaric Oxygen Therapy for brain-injured children. She is very, very interested because she was a practicing neonatalogist for 20+ years.

She told me that if a Texas Medicaid recipient asked for HBOT, they would probably grant it based on Paragraph 5 of the EPSDT statute.

Ten years ago Paragraph 5 was added specifically to make up for lost time. It reads "(5) Such other necessary health care, diagnostic services, treatment, and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan."

If you look carefully you'll see that the phrase "medically necessary" is no where to be found--even though the phrase is present in each of the previous four paragraphs.

The first four paragraphs were for (1) screening services...indicated as medically necessary, (2) vision services...indicated as medically necessary, (3) dental services...indicated as medically necessary, and (4) hearing services...indicated as medically necessary.

It is no typographical error that "medically necessary" is not found in Paragraph 5. The authors knew that it can take as long as 10 or 15 years before a treatment, procedure, drug, or device could be categorized as "medically necessary".

Therefore the language of Paragraph 5 provides the opportunity for the EPSDT statute to create its own definition of medical necessity--to be made on the basis of whether the service is necessary to correct or ameliorate a defect or condition.

In the case of Hyperbaric Oxygen Therapy, the efficacy of the treatment can be verified by objective scientific analysis of SPECT-scan imaging before HBOT and after a certain number of treatments.

Incidentally, Medicaid was created by another Texan, Lyndon Baines Johnson--specifically for brain-injured children. When it was created in 1967, President Johnson stated "The problem is to discover, as early as possible, the ills that handicap our children. There must be continuing follow-up and treatment so that handicaps do not go untreated." (13 Congressional Record 2883. February 8, 1967).

According to my conversation with Texas Medicaid, they are more interested in enabling brain-injured children than in perpetuating disability.

David Freels, 2948 Windfield Circle, Tucker, GA 30084-6714 USA

770/491-6776 (phone and fax)

509/275-1618 (efax, sends fax as email attachment)

dfreels@mindspring.com

EDITOR'S NOTE: Each state has their own guidelines for coverage of HBO. Call your state Medicaid office's Prior Auth Office and ask how you can get HBO covered. Most, if not all, only cover if you go to a clinic with a doctor in attendance. The doctor must get a Medical Assistance prior authority billing number from the state in which you are from. Dr. Harch was able to do that for a family in Wisconsin. If you get a state to cover your child's HBO please let MUMS know so we can share this information. Remember the more we can document states paying the more this puts pressure on other states. Each state may need a presidence setting case in order to cover HBO. Those of you who have gotten HBO and can document improvements through a SPECT scan or physicains report, have a better chance of getting coverage.

Also insurance is covering about one third of the families getting HBO. If you get a denial, APPEAL! If you get another denial ask how the damage to the brain caused by an air embolism (a FDA covered condition) is any different that the damage to your child's brain damage. If you get another denial, still bill the insurance comapany or HMO yourself and many are getting checks in the mail.

Julie Gordon, MUMS National Parent To Parent Network