Medicaid Benefits

Medical Necessity
Out of State Medicaid Reimbursement
SSI-Related Benefits

Medicaid Overpayment
Termination of Benefits

Disability Requirement
Medicaid Processing
Failure to Submit Requested Information

Medical Necessity

AHCA may authorize or pay for certain durable medical equipment and services provided to a Medicaid recipient as medically necessary. The Agency for Health Care Administration’s action of denying the petitioner’s request for Medicaid coverage of a Novo TTF-100A was upheld when the petitioner failed to present evidence to prove that the device’s medical necessity. Medical necessity means the medical device or service meets the following five conditions; one of those conditions which is that the service must be consistent with generally accepts professional medical standards. There has only been one published clinical trial for the Novo TTF-100A. Therefore, the Department concluded that the device is experimental and does not meet the medical necessity conditions. Fla. Admin. Code 59G-1.010(166) Fla. Admin. Code 59G-1.010(166),- 14F-10259

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. Medicaid may authorize or pay for certain durable medical equipment and services provided to a Medicaid recipient as medically necessary. The Agency’s action of denying the petitioner’s request for Home and Community Based Services Medicaid coverage based on the contention that she did not meet a Level of Care was remanded when the evidence presented showed that the Department failed to submit the § Referral for Home and Community Based Waiver Services§ to the CARES unit. The CARES unit was unable to consider the Petitioner’s application for the Medicaid program. Therefore, the Department’s decision to deny the Petitioner’s application was premature. Fla. Admin. Code 59G-1.010(166) Fla. Admin. Code 59G-1.010(166),- 14F-09676

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. Medicaid may authorize or pay for certain durable medical equipment and services provided to a Medicaid recipient as medically necessary. The Medicaid Long Term Care Waiver program allows patients to receive a certain number of home health service hours. The Petitioner requested 49 hours of weekly personal care and homemaker services, 42 hours for assistance with the activities of daily living and 7 hours for assistance with placement and activation of a device that helps the petitioner breathe while she sleeps. § United approved 39 hours weekly for assistance with activities of daily living and general household duties The Petitioner acknowledged that this is sufficient time for those duties. Therefore, the Department’s action of denying the Petitioner’s request for 7 hours requested for assistance with placement and activation of a device that helps the petitioner breathe while she sleeps was upheld when the petitioner failed to request Medicaid coverage for this skilled care service. Fla. Admin. Code 59G-1.010(166) Fla. Admin. Code 59G-1.010(166),- 14F-10179

Dental services is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. AHCA may authorize or pay for certain durable medical equipment and services provided to a Medicaid recipient as medically necessary. The Agency for Health Care Administration’s action of denying the petitioner’s request for a lower arch partial denture was upheld when the evidence presented showed that the Petitioner had sufficient molars and premolars in her lower mandible to chew food upon receiving the upper denture. Therefore, the lower arch partial denture was deemed to not be medically necessity. Fla. Admin. Code 59G-1.010(166),- 14F-09635

Orthodontic services is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. AHCA may authorize or pay for certain durable medical equipment and services provided to a Medicaid recipient as medically necessary. The Agency for Health Care Administration’s action of denying the petitioner’s request for orthodontic services (braces) was upheld when the petitioner only provided evidence that showed that the petitioner has a misalignment of teeth and that the petitioner might benefit from braces instead of providing proof that braces are medically necessary. Therefore, the petitioner’s request was denied because the petitioner did not establish the required proof of medically necessity. Fla. Admin. Code 59G-1.010(166),- 14F-10191

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The prior authorization process requires a list of documents that allow the Department to determine whether the surgery is medically necessary. AHCA may authorize or pay for certain durable medical equipment and services provided to a Medicaid recipient as medically necessary. The Agency for Health Care Administration’s action of denying the petitioner’s request for reimbursement for out-of-pocket expenses was upheld when the petitioner failed to request prior authorization. Fla. Admin. Code 59G-1.010(166),- 14F-09860

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The prior authorization process requires a list of documents that allow the Department to determine whether the surgery is medically necessary. AHCA may authorize or pay for certain durable medical equipment and services provided to a Medicaid recipient as medically necessary. The Agency for Health Care Administration’s action of denying the petitioner’s request for reimbursement for travel expenses was upheld when the petitioner failed to request prior authorization. Fla. Admin. Code 59G-1.010(166),- 14F-08341

Statewide Inpatient Psychiatric Program services must be prior authorized by Medicaid in order for the service to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The prior authorization process requires a list of documents that allow the Department to determine whether the service is medically necessary. Medicaid services must be reflective of the level of service for which no equally effective and more conservative or less costly treatment is available, such as outpatient treatment. The evidence presented showed that the Petitioner’s diagnosis of “mood disorder-NOS” is vague and does not support a severe psychiatric condition. . Therefore, the Agency’s action to deny the petitioner’s request for the program’s services was upheld. Fla. Admin. Code 59G-1.010(166),- 14F-09200

Statewide Inpatient Psychiatric Program services must be prior authorized by Medicaid in order for the service to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The prior authorization process requires a list of documents that allow the Department to determine whether the service is medically necessary. Medicaid services must be reflective of the level of service for which no equally effective and more conservative or less costly treatment is available. The evidence presented failed to show that the breaking the services into smaller segments proved to be unsuccessful. Therefore, the Agency’s action to deny the petitioner’s request for the program’s services was upheld. Fla. Admin. Code 59G-1.010(166),-14F-09669

Statewide Inpatient Psychiatric Program services must be prior authorized by Medicaid in order for the service to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The prior authorization process requires a list of documents that allow the Department to determine whether the service is medically necessary. Medicaid services must be reflective of the level of service for which no equally effective and more conservative or less costly treatment is available, such as outpatient treatment. The evidence presented showed that the Petitioner’s condition and disorders do not require psychiatric program services. Therefore, the Agency’s action to deny the petitioner’s request for the program’s services was upheld. Fla. Admin. Code 59G-1.010(166),- 14F-10487

Laparoscopic Sleeve Gastrectomy services must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The prior authorization process requires a list of documents that allow the Department to determine whether the surgery is medically necessary. A gastrectomy must be deemed to be medically necessary in order for the Department to approve the petitioner’s request for a surgery. The Department’s action to deny the petitioner’s request for a laparoscopic sleeve gastrectomy was upheld where the petitioner failed to provide evidence against the dental consultant’s opinion that the procedure is a maintenance service rather than an emergency service. Fla. Admin. Code 59G-1.010(166),- 14F-10033

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action to partially deny the petitioner’s request for personal care service was upheld when the petitioner failed to prove that the service was medically necessary. The evidence showed that only two hours daily in the afternoon is medically necessary to provide assistance to the Petitioner with ADL needs and the Petitioner’s mother is available in the morning to address ADL needs.Therefore, the evidence did not support the authorization of personal care hours § because the alternative service was better designed to meet the petitioner’s needs without being excessive. Fla. Admin. Code 59G-1.010(166),- 14F-09199

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action to deny the Petitioner’s request for four units (one hour) of Occupational Therapy three times a week and approve four units once a week was upheld when the evidence showed that the Petitioner’s family is capable of continuing to provide occupational therapy for the Petitioner on their own . Fla. Admin. Code 59G-1.010(166),- 14F-09708

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action to deny the Petitioner’s request for seven hours of personal care services (PCS) and approving three days a week was upheld when the services requested were not considered emergency services. Fla. Admin. Code 59G-1.010(166),- 14F-09522

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action to deny the petitioner’s request for a pulse oximeter,disposable pulse oximeter probes and adult wipes was partially upheld when the evidence showed that while the § pulse oximeter was medically necessary, there were more affordable alternatives for the adult wipes. § Fla. Admin. Code 59G-1.010(166),- 14F-09519

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action to terminate Petitioner’s Prescribed Pediatric Extended Care via a 30-day fade/transition was upheld when the petitioner failed to prove that the service was medically necessary. There was no evidence presented by the Petitioner was dependent on 24-hour per day medical or nursing care, or that he is dependent upon life-sustaining medical equipment. The evidence showed that the Petitioner did not require daily skilled nursing intervention other than the daily injection which can be provided by a nursing visit. Therefore, the evidence did not support the authorization of PPEC because the alternative service was better designed to meet the petitioner’s needs without being excessive. Fla. Admin. Code 59G-1.010(166),- 14F-09214

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action to deny the petitioner’s request for Prescribed Pediatric Extended Care was upheld when the petitioner failed to prove that the service was medically necessary. There was no evidence presented by the Petitioner was dependent on 24-hour per day medical or nursing care, or that he is dependent upon life-sustaining medical equipment. The evidence showed that the Petitioner did not require daily skilled nursing intervention other than the daily injection which can be provided by a nursing visit. Therefore, the evidence did not support the authorization of PPEC because the alternative service was better designed to meet the petitioner’s needs without being excessive. Fla. Admin. Code 59G-1.010(166),- 14F-09058

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action to deny the petitioner’s request for Personal Care Assistant services was upheld when when the requested § hours fell within the definition of flex hours. Therefore, the petitioner’s needs did not support the authorization of additional services because the alternative service was better designed to meet the petitioner’s needs without being excessive. Fla. Admin. Code 59G-1.010(166),-14F-09428

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action to deny the petitioner’s request for continuation of residential treatment through Statewide Inpatient Psychiatric Program was reversed when the greater weight of evidence established that the petitioner’s psychiatric condition required inpatient psychiatric treatment and reasonable that further treatment would positively impact the petitioner’s psychiatric status.Therefore, the petitioner’s supported the authorization of additional services and the Agency’s action was reversed. Fla. Admin. Code 59G-1.010(166),-14F-09431

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action to deny the petitioner’s request for Personal Care Assistant services was upheld when when the requested § hours fell within the definition of flex hours. Therefore, the petitioner’s needs did not support the authorization of additional services because the alternative service was better designed to meet the petitioner’s needs without being excessive. Fla. Admin. Code 59G-1.010(166),-14F-09426

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action to deny the petitioner’s request for Prescribed Pediatric Extended Care was upheld when the petitioner failed to prove that the service was medically necessary. There was no evidence presented by the Petitioner was dependent on 24-hour per day medical or nursing care, or that he is dependent upon life-sustaining medical equipment. Therefore, the petitioner’s needs did not support the authorization of PPEC because the alternative service was better designed to meet the petitioner’s needs without being excessive. Fla. Admin. Code 59G-1.010(166),- 14F-08795

Dental procedures must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the petitioner’s reimbursement of dental expenses incurred was upheld when the services secured by the petitioner in 2011 did not appear on the Dental General Fee Schedule as reimbursable services. Therefore, the Department did not allow reimbursement for the dental work. § Fla. Admin. Code 59G-1.010(166),- 14F-09536

Dental procedures must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the petitioner’s request for dental work, including dental crowns and moldings was upheld when the petitioner failed to provide compelling evidence or testimony to show that the medically necessary requested procedures. In order for services requested to be determined to be medically necessary and meet any additional requirements.Therefore, the Department did not allow reimbursement for the dental work. § Fla. Admin. Code 59G-1.010(166),- 14F-09528

Dental procedures must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the petitioner’s request for dental work, including dental crowns and moldings was upheld when the petitioner failed to prove that the service was medically necessary. Therefore, the Department did not allow reimbursement for the dental work. § Fla. Admin. Code 59G-1.010(166),- 14F-08646

Dental procedures D9630 and D9911 must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the petitioner’s request for reimbursement of $150.00 for dental procedures was upheld where the petitioner did not experience an erroneous denial of Medicaid eligibility which contributed to the denial of the dental procedures at issue. Therefore, the Department did not allow reimbursement Fla. Admin. Code 59G-1.010(166),- 14F-10905

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The prior authorization process requires a list of documents that allow the Department to determine whether the surgery is medically necessary. AHCA may authorize or pay for certain durable medical equipment and services provided to a Medicaid recipient as medically necessary. The Agency for Health Care Administration’s action of denying the petitioner’s request for additional Home Health Aide services was upheld the petitioner failed to prove that the additional services requested are for anything other than supervision and monitoring and the respondent did not provide evidence from a healthcare professional indicating that the additional services are medically necessary. Fla. Admin. Code 59G-1.010(166),- 14F-09327

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The prior authorization process requires a list of documents that allow the Department to determine whether the surgery is medically necessary. AHCA may authorize or pay for certain durable medical equipment and services provided to a Medicaid recipient as medically necessary. The Agency for Health Care Administration’s action of denying the petitioner’s request for a skin removal surgical procedure § was upheld when the petitioner failed to request prior authorization. Fla. Admin. Code 59G-1.010(166),- 14F-08944

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to terminate the petitioner’s receipt of brand name adult diapers and pull-ups and replace them with generic adult diapers and pull-ups, and then to terminate the petitioner’s § receipt of adult pull-ups altogether was not upheld. The Petitioner has demonstrated that the brand specific diapers and pull ups are medically necessary in her case. Therefore, the petitioner’s appeal was granted. Fla. Admin. Code 59G-1.010(166),- 14F-08928

Reduction mammoplasty services must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The prior authorization process requires a list of documents that allow the Department to determine whether the surgery is medically necessary. Mammoplasty services must be deemed to be medically necessary in order for the Department to approve the petitioner’s request for a surgery. The Department’s action to deny the petitioner’s request for bilateral breast reduction (mammoplasty) was upheld where the petitioner failed to provide all of the required documentation necessary for prior authorization of the bilateral breast reduction surgery. Fla. Admin. Code 59G-1.010(166),- 13F-11188

A request for a speech generating communication device, along wither accessories for the device must be prior authorized by Medicaid in order for the device to be deemed medically necessary. A device is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The prior authorization process requires a list of documents and evaluations that allow the Department to determine whether the surgery is medically necessary. The device must be deemed to be medically necessary in order for the Department to approve the petitioner’s request for a device. The Department’s action to deny the petitioner’s request was upheld when the petitioner did not prove that she has the physical, cognitive and language abilities necessary to use the device. Also, there was no evidence that the petitioner was evaluated by an interdisciplinary team consisting of at least two members of different professional discipline, as required in program rule. Fla. Admin. Code 59G-1.010(166),- 14F-4684

A request for a Jazzy Elite 14 Power Wheelchair must be prior authorized by Medicaid in order for the device to be deemed medically necessary. A device is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The prior authorization process requires a list of documents and evaluations that allow the Department to determine whether the surgery is medically necessary. The device must be deemed to be medically necessary in order for the Department to approve the petitioner’s request for a wheelchair. The Department’s action to deny the petitioner’s request was upheld when the petitioner did not prove that the petitioner has the cognitive, problem solving, awareness or visual ability to be safe in the wheelchair or that his home is accessible. Therefore, Sunshine Health could not approve the wheelchair. Fla. Admin. Code 59G-1.010(166),- 14T-2512

PET scans must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The prior authorization process requires a list of documents that allow the Department to determine whether the surgery is medically necessary. The Department’s action to deny the petitioner’s request for PET scans was upheld when the petitioner and her physician’s request for PET scans failed to include a description of detailed history and/or physical examination relevant to the imaging procedure requested. Fla. Admin. Code 59G-1.010(166),- 14F-3574

Bathroom modifications must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The prior authorization process requires a list of documents that allow the Department to determine whether the bathroom modifications are medically necessary. The Department’s action to deny the petitioner’s request for bathroom modifications was upheld when the evidence presented showed that the petitioner’s hygienic needs are being met by the petitioner’s current PCA/HHA needs. Fla. Admin. Code 59G-1.010(2)(166),- 14F-3723

Reduction mammoplasty services must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The prior authorization process requires a list of documents that allow the Department to determine whether the surgery is medically necessary. Mammoplasty services must be deemed to be medically necessary in order for the Department to approve the petitioner’s request for a surgery. The Department’s action to deny the petitioner and her physician’s request for a prior bilateral breast reduction (mammoplasty) that would cover as payment of a medical procedure for the petitioner through Medicaid was upheld when the Petitioner failed to provide evidence that showed that the medical procedure was medically necessary. Fla. Admin. Code 59G-1.010(166),- 14F-0897

The prior authorization process requires a list of documents that allow the Department to determine whether the surgery is medically necessary. The service must be deemed to be medically necessary in order for the Department to approve the petitioner’s request for a medical service. The Department’s action to deny the petitioner’s request for Health Care Administration to provide the petitioner with a letter of authorization for an MRI was not upheld when the evidence showed that the petitioner was not actively enrolled in Medicaid. Consequently, since was no denial of services, the hearing officer was not able to rightfully take jurisdiction over the matter and render a decision. Fla. Admin. Code 59G-1.010(166),- 14F-891

The prior authorization process requires a list of documents that allow the Department to determine whether the surgery is medically necessary. The service must be deemed to be medically necessary in order for the Department to approve the petitioner’s request for a medical service. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s decision to partially deny the Petitioner’s request for a partial lower denture was upheld when the Petitioner failed to provide current radiographs within his prior authorization documents. . Fla. Admin. Code 59G-1.010(166),- 14F-2306

The prior authorization process requires a list of documents that allow the Department to determine whether the surgery is medically necessary. The service must be deemed to be medically necessary in order for the Department to approve the petitioner’s request for a medical service. The Department’s action to deny the petitioner’s request for prior authorization of an MRI was correctly denied by respondent was not upheld when the petitioner failed to prove, by a preponderance of the evidence, that an MRI meet the medically necessary threshold for Medicaid payment. Also, the Medicaid rule prohibits provision of services in excess of patient’s needs. Fla. Admin. Code 59G-1.010(166),- 14F-955

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. AHCA may authorize or pay for certain durable medical equipment and services provided to a Medicaid recipient as medically necessary. The Department’s action of partially denying the petitioner’s request for 8 additional hours of personal care services 7 days a week for a certification period and approving 2 hours of personal care 7 days a week was upheld when the petitioner failed to meet the required burden of proof in demonstrating medical necessity for the level of service requested. The Department found that while the petitioner is four years old and needs supervision when the parents are working, supervision is not covered by Medicaid and that the 2 hours of personal care services 7 days a week were sufficient to meet the petitioner’s needs because the mother was self-employed and could adjust her work schedule. Fla. Admin. Code 59G-1.010(166),- 14F-3149

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. AHCA may authorize or pay for certain durable medical equipment and services provided to a Medicaid recipient as medically necessary. The Department’s action of canceling the petitioner’s enrollment requirements of the Program was upheld when the respondent found that the petitioner no longer met the requirements to receive benefits. The Department found that the petitioner should not have been enrolled in the Long Term Care Program because he was no longer residing in a nursing home and was not on any Medicaid Waiver waiting list. Therefore, as the petitioner did not reside in a nursing home and was not on any Medicaid Waiver waiting list the hearing officer agrees with the Agency decision that the petitioner does not meet the eligibility requirements to be enrolled in the Long Term Care Program. Fla. Admin. Code 59G-1.010(166),- 14F-3150

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. AHCA may authorize or pay for certain durable medical equipment and services provided to a Medicaid recipient as medically necessary. The Department’s action of cancelling the petitioner’s enrollment requirements of the Program was upheld when the cumulative evidence presented showed that the petitioner does not require nursing facility care. The petitioner is not residing in a nursing home facility, nor is she enrolled in an eligible long-term care Medicaid waiver program. Fla. Admin. Code 59G-1.010(166),- 14F-21070

The Department’s action to partially deny petitioner’s request for extraction of her impacted wisdom was not upheld when the Department found that the Respondent wrongfully denied the requested services. The requested services do not require prior authorization per the Dental General Fee Schedule and MCNA’s services cannot be more restrictive than fee-for service. Fla. Admin. Code R. 59G- 4.060 –14F-2385

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. AHCA may authorize or pay for certain durable medical equipment and services provided to a Medicaid recipient as medically necessary. The Department’s action to deny licensed practical nurse (LPN) service hours that were requested for the Petitioner for the certification period December 12, 2013 through June 9, 2014 was upheld when the requested services were no longer medically necessary. Even though the Petitioner’s physician ordered LPN services greater that what was approved by eQHealth Solutions, a prescription does not automatically mean the requirements of medically necessary have been satisfied. However, since the physician should qualify for skilled nursing visits, the effective date of this order was delayed 30 days to allow the petitioner to apply for those other services. Fla. Admin. Code 59G-1.010(166),59G-4.070(2),-14F-803

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. AHCA may authorize or pay for certain durable medical equipment and services provided to a Medicaid recipient as medically necessary. Direct payment may be made to a recipient who paid for medically necessary, Medicaid services received from the beginning date of eligibility and paid for during the period of time between an erroneous denial or termination of Medicaid eligibility and a successful appeal or an agency determination in the recipient’s favor. The Department’s action to deny petitioner’s request for reimbursement for travel expenses associated with a dental appointment on January 7, 2014 was upheld when the petitioner failed to follow the prior authorization process as demonstrated by attempting to contact Flagler County Transport and having (FCT) authorize the transportation before traveling to the dental appointment. Fla. Admin. Code 59G-5.110(1)(a), 59G-4.330-14F-0882

AHCA may authorize or pay for certain durable medical equipment and supplies provided to a Medicaid recipient as medically necessary. The Department’s action of denying the petitioner’s request for an iPad for the certification period of 11/13/2013- 5/11/2014 was upheld when the Department found that the device was not an appropriate device for addressing the petitioner’s speech and language deficits. Fla. Admin. Code 59G-1.010(166),59G-4.070(2),-14F-0507

AHCA may authorize or pay for certain durable medical equipment (DME) and supplies provided to a Medicaid recipient as medically necessary. The Department’s action of denying the petitioner’s request for a new wheelchair with standing components was denied when the Department found that the DME was covered by Medicaid.Fla. Admin. Code 59G-1.010(166),59G-4.070(2),-14F-0520

AHCA may authorize or pay for certain durable medical equipment (DME) and supplies provided to a Medicaid recipient as medically necessary. The Department’s action of denying the petitioner’s request for a customized was upheld when the petitioner failed to provide evidence to show that the requested additional wheelchair features were effective and the least costly alternative. Admin. Code 59G-1.010(166),59G-4.070(2),-14F-0524

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. AHCA may authorize or pay for certain durable medical equipment and supplies provided to a Medicaid recipient as medically necessary. Services for individuals under 21 are determined under a broader definition of medically necessary, the Early and Periodic Screening, Diagnosis, and Treatment Services (EPSDT) requirement, which states that services must be medically necessary for the treatment, correction, or amelioration of problems addressed by appropriate services. The petitioner originally requested an additional four units/ one hour per week of Occupational Therapy, his request was denied because the Department did not believe that the additional occupational treatment was medically necessary . The Department’s decision to deny the Petitioner’s request for an additional four units/ one hour per week of Occupational Therapy was reversed. Upon review of all testimony and evidence presented to the Department, the evidence showed that the Petitioner requires an additional four units per week to address the effects of his deficits and the underlying causes of the deficits. Fla. Admin. Code 59G-1.010(166),59G-4.070(2),-13F-12121

The petitioner originally requested payment for a MRI of the Lower Extremity or left knee. The Department’s decision to deny the Petitioner’s request was reversed when the Respondent agreed to approve the Petitioner’s request on the record. Fla. Admin. Code 59G-1.010(166),59G-4.070(2),-13F-12239

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s decision to partially deny the Petitioner’s request for dental services was reversed when the Petitioner, who suffers from gum disease, presented evidence that she was ordered by her doctor to have her remaining teeth removed in order to prevent serious medical complications. Fla. Admin. Code 59G-1.010(166),59G-4.070(2) –14F-0232

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s decision to partially deny the Petitioner’s request for dental services was upheld when the only dentist that appeared at the hearing, testified that the petitioner’s top wisdom teeth are straight, not tipped, or impacted and there is no evidence of decay or infection. Therefore, it was not medically necessary to extract the upper wisdom teeth. Fla. Admin. Code 59G-1.010(166), 59G-4.070(2) –14F-4807

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s decision to partially deny the Petitioner’s request for Speech Therapy service hours that were requested for the petitioner for the certfication period was upheld when the petitioner failed to meet the required burden of proof. The respondent’s witness, stated that she believed that 2 hours of weekly speech therapy service was medically necessary for the petitioner at this time because his test scores show only a mild delay and a home therapy program could be utilized to supplement the therapy sessions. Fla. Admin. Code 59G-1.010(166),59G-4.070(2),-14F-2904

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s decision to deny the Petitioner’s request for extraction of his tooth, excision of a tumore or lesion in the surrounding area, and sedation during the procedure was not upheld when it was found that the Respondent’s denial was fundamnetally improper as the requested services do not require prior authorization. Fla. Admin. Code 59G-1.010(166),59G-4.070(2),-14F-2914

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s decision to deny the Petitioner’s request for Home Health Aide (HHA) services was upheld when the Department found that the requested service is not avaiable to adults over age 21. Since the petitioner is 22 years of age, she is eligible to receive Home Health Aide visits but not continuous Personal Care Assistant services. Home Health Aide visits are limited to a maximum of three intermittent visits per day for non-pregnant adults age 21 and older, and the minimum length of time between home health visits provided to a recipient on the same day must be at least one hour. Fla. Admin. Code 59G-1.010(166), 59G-1.010-14F-2899

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s decision to deny the Petitioner’s request for twenty-four hours of personal care assistance (PCA) is correct was not upheld where while on the record, the parties agreed the respondent would approve the following for petitioner PCA hours are for ER’s certification period. Fla. Admin. Code 59G-1.010(166),59G-4.070(2),-14F-2315,2314

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. Also, the provider in this instant case, Med Solutions requires that services must be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs. The Department’s decision to deny the Petitioner’s request for a CT Scan of the head was upheld when information submitted by the provider was insufficient to obtain prior approval for a CT Scan by MedSolutions. Fla. Admin. Code 59G-1.010(166),59G-4.070(2),-14F-0237

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. AHCA may authorize or pay for certain durable medical equipment and supplies provided to a Medicaid recipient as medically necessary. Services for individuals under 21 are determined under a broader definition of medically necessary, the Early and Periodic Screening, Diagnosis, and Treatment Services (EPSDT) requirement, which states that services must be medically necessary for the treatment, correction, or amelioration of problems addressed by appropriate services. The petitioner originally requested an additional four units/ one hour per week of Occupational Therapy,three times per week, the petitioner’s request was denied because the Department did not believe that the additional occupational treatment was medically necessary . The Department’s decision to partially deny the Petitioner’s request for an additional four units/ one hour per week of Occupational Therapy was reversed. Upon review of all testimony and evidence presented to the Department, the evidence showed that the Petitioner requires the additional units per week because the petitioner was performing below age-level in areas like motor coordination and visual motor integration. Therefore, the services were medically necessary. Fla. Admin. Code 59G-1.010(166),59G-4.070(2),-14F-0239

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for an Inflatable Penile Prosthesis was upheld when the respondent argued that there were more conservative remedies are available which the Petitioner is not willing to try. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 14F-08924

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for an MRI scans was upheld when the respondent argued that there were more conservative remedies are available which the Petitioner is not willing to try. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 14F-10822

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for an CT scan of the petitioner’s neck was upheld when the petitioner failed to prove that the CT scans were medically necessary. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-00028

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for an PET scan was upheld when the petitioner failed to prove that the PET scans were medically necessary. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-00077

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for a procedure 75881: tumor imaging, positron emission tomography with concurrently acquired computed tomography for attenuation correction and anatomical localization; skull base to mid-thigh was upheld when the petitioner failed to prove that the requested procedures were medically necessary. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-00361

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for magnetic resonance imaging of the lumbar spine and his request to see an out of network provider when the Petitioner failed to meet his burden of proof to show the out-of-network provider request .Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-00653

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for an MRI scan of the left knee was upheld when the respondent argued that there were more conservative remedies. Also, the Petitioner had not demonstrated that more conservative treatments have failed. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-00002

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for an additional personal care, homemaker and companion services through the Statewide Long Term Managed Care Program was upheld when the Petitioner failed to demonstrate that 90 hours of personal care was medically necessary. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-01136

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for an additional personal care, homemaker and companion services through the Statewide Long Term Managed Care Program was upheld when the Petitioner failed to demonstrate that 50 hours of personal care was medically necessary. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 14F-09110

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for services from Statewide Inpatient Psychiatric Program was upheld when the Respondent found out that the services were not medically necessary. The program was designed to aid individuals with a severe psychological illness, and even though the Petitioner has a severe substance abuse problem, the program is not appropriate to meet his needs. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 14F-10374

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of cancelling the petitioner’s request for Prescribed Pediatric Extended Care was upheld when the petitioner failed to prove that the service was medically necessary. There was no evidence presented by the Petitioner was dependent on 24-hour per day medical or nursing care, or that he is dependent upon life-sustaining medical equipment. Therefore, the petitioner’s needs did not support the authorization of PPEC because the alternative service was better designed to meet the petitioner’s needs without being excessive. Fla. Admin. Code 59G-1.010(166),- 14F-09007

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of reducing the petitioner’s personal care, homemaker, companion and skilled nursing services was not upheld when the evidence and the testimony established that the petitioner’s medically necessary unskilled service needs have not decreased. Rather, respondent’s own assessment tool identified a high level of needed support with most, if not all, activities of daily living. Therefore, the petitioner’s needs supported the authorization of additional service hours. Fla. Admin. Code 59G-1.010(166),- 14F-10190

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for outpatient hospital services was upheld when the evidence showed that the Petitioner’s father may have given inaccurate information throughout the billing process which led him to believe Staywell would cover the claims. Therefore, the evidence did not support the authorization of outpatient hospital services . Fla. Admin. Code 59G-1.010(166),- 15F-01147

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for personal care services for a total of four hours a day was upheld when the evidence showed that an additional four hours of personal care services was not medically necessary. Therefore, the petitioner’s needs did not support the authorization of four additional hours, the petitioner was authorized to receive two additional hours instead . Fla. Admin. Code 59G-1.010(166),- 14F-10424

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for Adult Day Care services five days a week was not upheld when an accurate assessment of the Petitioner’s service needs and how they can be met should have been completed before any decision is made to reduce his days at the ADC. Therefore, the petitioner’s appeal was granted. Fla. Admin. Code 59G-1.010(166),- 15F-00627

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible.The Petitioner is seeking personal care service hours to assist with behavioral needs. Personal care service hours are not intended to assist with behavioral needs; they are for ADL assistance only. The Agency’s action of denying the petitioner’s request for additional personal care services was upheld when the evidence showed that additional personal care services were not medically necessary. Therefore, the petitioner’s needs did not support the authorization of additional hours, and the petitioner’s appeals instead . Fla. Admin. Code 59G-1.010(166),- 14F-10941

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for an increase in personal care was not upheld when the evidence showed that the petitioner’s parents were capable of providing care for the petitioner. Therefore, providing the petitioner with personal care services would be in excess of the petitioner’s needs and not medically necessary. Fla. Admin. Code 59G-1.010(166),- 15F-00364

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for personal care was not upheld when the evidence showed that the petitioner’s parents were capable of providing care for the petitioner. Therefore, providing the petitioner with personal care services would be in excess of the petitioner’s needs and not medically necessary. Fla. Admin. Code 59G-1.010(166),- 14F-10263,14F-10264

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for a reduction in his Institutional Care Program Medicaid patient responsibility was upheld when the Department concluded that the Department acted in accordance with its existing regulations and policies was upheld. Federal law allows the State to place reasonable limitations on the amount of medical expenses considered. The Department has imposed a three month limitation. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 14F-09084

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for a reduction in his Institutional Care Program Medicaid patient responsibility was upheld when the Department concluded that the Department acted in accordance with its existing regulations and policies was upheld. Federal law allows the State to place reasonable limitations on the amount of medical expenses considered. The Department has imposed a three month limitation. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 14F-09434

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for Institutional Care Program was reversed when the Department concluded that the Petitioner met the level of care and that the nursing home placement was appropriate. Therefore, the petitioner’s appeal was granted. Fla. Admin. Code 59G-1.010(166),- 14F-10860

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to partially deny the petitioner’s request for dental services was upheld when the petitioner failed to submit the necessary information for Medicaid to analyze in order to decide whether the services could be authorized. Therefore, the requested procedure was deemed to not be medically necessary. Fla. Admin. Code 59G-1.010(166),- 14F-10495

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to partially deny the petitioner’s request for partial upper and lower dentures was upheld when the evidence presented failed to meet two of the requirements for disability. Therefore, the requested procedure was deemed to not be medically necessary. Fla. Admin. Code 59G-1.010(166),- 14F-10688

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for a partial lower denture was upheld when the evidence showed that the request was in excess of the patient’s needs. Therefore, the requested procedure was deemed to not be medically necessary. Fla. Admin. Code 59G-1.010(166),- 14F-10576

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for crowns and/or dental services was upheld where the expert witnesses opined that the petitioner’s wisdom teeth were not crowded or impacting the petitioner’s frontal teeth. Therefore, the requested procedure was deemed to not be medically necessary. Fla. Admin. Code 59G-1.010(166),- 14F-10183

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental services was upheld when the evidence showed that the petitioner acquired the dental treatment without first receiving prior authorization of the treatment through Medicaid. Therefore, the requested procedure was deemed to not be medically necessary because the petitioner failed to meet the required burden of proof. Fla. Admin. Code 59G-1.010(166),- 14F-10431

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to partially deny the petitioner’s request for dental services was upheld where the expert witnesses opined that the petitioner’s wisdom teeth were not impacting the petitioner’s surrounding teeth. Therefore, the requested procedure was deemed to not be medically necessary. Fla. Admin. Code 59G-1.010(166),- 14F-10184

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action to deny the petitioner’s request for Prescribed Pediatric Extended Care was upheld there is no evidence to suggest that petitioner is dependent upon 24-hour per day medical or nursing care, or that he is dependent upon life-sustaining medical equipment, such that he would be deemed “medically complex” or “medically fragile”. Therefore, the Agency’s action was affirmed and appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-01746

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for services from Statewide Inpatient Psychiatric Program was upheld when the Respondent found out that the services were not medically necessary. The program was designed to aid individuals with a severe psychological illness and the evidence showed that the alternatives were not explored. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-00826

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for services from Statewide Inpatient Psychiatric Program was not upheld when the petitioner proved that the requested service was medically necessary. The petitioner was diagnosed with multiple psychological disturbances and previously received treatment in a less restrictive setting and the treatment was ineffective. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-02145

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for services from Statewide Inpatient Psychiatric Program was upheld when the Respondent found out that the services were not medically necessary. There was no evidence submitted that showed that alternate methods were proven to be unsuccessful. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-02970

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for services from Statewide Inpatient Psychiatric Program was upheld when the Respondent found out that the services were not medically necessary because there was no evidence presented to show the petitioner meets criteria for exemption from mandatory participation in the statewide managed care program. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-01144

Dental procedures must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the petitioner’s request for dental services was upheld because the services were not covered and failed to show that the requested procedures were emergency dental procedures to alleviate pain or infection as required above. Therefore, the Department denied the petitioner’s appeal. Fla. Admin. Code 59G-1.010(166),- 15F-00313

Dental procedures must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the petitioner’s request for upper and partial lower dentures was upheld when the petitioner failed to meet her burden of proving the medical necessity of her requested products. Therefore, the Department denied the petitioner’s appeal. Fla. Admin. Code 59G-1.010(166),- 15F-02675

Dental procedures must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the petitioner’s request for dental services was upheld because the petitioner failed to meet her burden of proving the medical necessity of her requested procedure. Therefore, the Department denied the petitioner’s appeal. Fla. Admin. Code 59G-1.010(166),- 15F-02435

Dental procedures must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the petitioner’s request for dental services was upheld because the petitioner failed to meet her burden of proving the medical necessity of her requested procedure. Therefore, the Department denied the petitioner’s appeal. Fla. Admin. Code 59G-1.010(166),- 15F-02756

Dental procedures must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the petitioner’s request for pest control services was upheld because the petitioner failed to meet her burden of proving the medical necessity of her requested procedure. Therefore, the Department denied the petitioner’s appeal. Fla. Admin. Code 59G-1.010(166),- 15F-02971

Dental procedures must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the petitioner’s request for dental services was upheld because the petitioner failed to meet her burden of proving the medical necessity of her requested procedure. Therefore, the Department denied the petitioner’s appeal. Fla. Admin. Code 59G-1.010(166),- 15F-02535

The Department’s action to deny the petitioner’s request for reimbursement of dental expenses was partly upheld. The Medicaid authority states that a Medicaid recipient incurs an out-of-pocket medical expense from a non-Medicaid expenses from a non-Medicaid provider during a period of Medicaid eligibility. In this case, the service is constituted as an emergency, the cost of that service should be reimbursed to Petitioner’s GA. Also, the Petitioner has Agreed to be reimbursed according to the fee schedule. Per the fee schedule, patients are reimbursed at the rate of $16.35. Therefore, the Petitioner’s appeal was denied with regard to the reimbursement for 9 fillings and granted with regard to the pulp cap/medicated filing. Respondent is instructed to reimburse Petitioner at no less than $16.35, in accordance with the appropriate fee schedule. Fla. Admin. Code 59G-1.010(166),- 15F-00633

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for a Functional Electronic Stimulation device was upheld when the Respondent concluded the device is considered experimental and investigational and is not a medical necessity. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 14F-10044

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for braces and 24 treatment visits was upheld when the Department concluded the petitioner did not meet the criteria for medical necessity for the requested service and product. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-03595,15F-04106

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for periodontal scaling and root planing was upheld when the hearing officer concluded that Petitioner’s request for deep cleaning is outside the scope of services to which she is entitled under her benefit plan. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-03883

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for orthodontic services (braces) was upheld when the Department concluded the braces were considered experimental and investigational and is not a medical necessity. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-02598

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for three cans of Boost High Protein Oral Liquid nutritional supplement per day was not upheld when the Respondent failed to show that it was proper to stop providing Petitioner’s Boost. Also, the Respondent failed to prove Petitioner is able to obtain all of her nutrition from solid food alone. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-02142

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for a lap sleeve gastrectomy was not upheld when it was found that the evidence showed that the petitioner met the burden of proving that the gastrectomy was medically necessary because the petitioner tried alternatives that did not relieve her condition. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-01880

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for a intravenous moderate sedation/anaglesia during extraction surgery to remove impacted bony, wisdom teeth was not upheld when the undersigned found that the Respondent’s denial was fundamentally improper as the requested services do not require prior authorization.Fla. Admin. Code 59G-1.010(166),- 15F-03313

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for a lap sleeve gastrectomy was upheld when it was found that the evidence contained a diet log prepared by the petitioner and submitted after the pre-authorization request was denied on January 27, 2015 and containing only three days of diet information. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-01702

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for Durable Medical Equipment was upheld when there was evidence submitted that showed that the product was medically necessary Therefore, the petitioner’s appeal was granted. Fla. Admin. Code 59G-1.010(166),- 15F-03423

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for Durable Medical Equipment was upheld when there was no documentation submitted by the petitioner. The Agency cannot approve DME without necessary supporting documentation justifying the request. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-02392

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for Durable Medical Equipment was not upheld when the petitioner proved that the requested equipment was medically necessary. Therefore, the petitioner’s appeal was granted. Fla. Admin. Code 59G-1.010(166),- 15F-03673

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for prescription medication Zofran at the 4 tablets per day dosagewas upheld when the submitted documentation did not support the need or explain why he needed to exceed the maximum amount. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-03221

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for an L2 to L3 discectomy (CPT 63056) was upheld when there was no evidence submitted that showed that the service was medically necessary.Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-02413

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for a positron emission tomography (PET) scan was upheld when the petitioner failed to demonstrate, by the required evidentiary standard, that respondent’s action in this matter was incorrect. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-01914

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for lidocaine 5% adhesive patches (lidocaine patches) was upheld when no medical documentation was presented that other pain protocols have been attempted and failed. Therefore, the petitioner failed to prove that patches were medically necessary and the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-02143

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for a Physical Therapy service hours for the certification period was upheld when the Petitioner has not met the burden of proof in demonstrating the Respondent was incorrect in partially denying the requested physical therapy services for the certification period. Although the Petitioner may have experienced a decline in muscle strength due to his recent surgery, his treating physician and his therapist do not explain in their letters why two hours weekly of physical therapy is insufficient to accomplish an increase in muscle strength. Therefore, the Department’s action was approved and the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-01834

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for a magnetic resonance imaging of petitioner’s cervical and lumbar spine was upheld when there was no evidence that showed a trial of physical therapy was attempted and determined to to be ineffective by a medical professional. Additionally, the evidence did not establish other conservative protocols such as chiropractic care or a supervised home exercise program have been attempted. Therefore, the Department’s action was affirmed and the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-01742

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for a magnetic resonance imaging of petitioner’s cervical and lumbar spine was upheld when it was found that a CT scan was a more conservative procedure than the MRI or PET scan. Therefore, the Department’s action was affirmed and the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-02751

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for a polysomnography study was upheld when the evidence did not support the need for a Polysomnogram. Therefore, the Respondent concluded the device is considered experimental and investigational and is not a medical necessity and the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-00799

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to terminate the Petitioner’s meal service was upheld when it was found that the Petitioner’s request for the meal service was in excess of the Petitioner’s needs or duplicative of another service. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-01698

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for a chest compression device was upheld when it was found that the petitioner’s current chest compression device was working properly and effective at accomplishing its intended goal. Therefore, the evidence shows that the petitioner is compliant with her use of the existing equipment and the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-01701

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for home modifications (ramps, door widening, and tub to shower modification) and hours of assistance was upheld when the respondent appropriately denied the request as it does not meet medical necessity under the controlling Medicaid authorities. Therefore, the Department’s action was affirmed and the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-01885

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for a prescription for SOMA (carisoprodol). Therefore, the Respondent concluded that the petitioner did not prove that the prescription was medically necessary for ongoing use of the SOMA medication from her physician and the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-01141

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for a new wheelchair was upheld when the Petitioner failed to submit the necessary documentation necessary to prove medical necessity. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 14F-08498

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the request for a prescription medication Harvoni was upheld when the Petitioner failed to meet the burden of proof to show that this particular medication is medically necessary and that there are no clinically acceptable alternatives. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-00630

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for an increase in the hours of home health services hours she receives through the Medicaid Long Term Care Waiver program from 107 hours weekly to 123 hours weekly when the Respondent determined that additional service hours are not medically necessary because she currently receives 15 hours of service daily and is capable of being alone approximately three hours at a time. Therefore, providing the petitioner with personal care services would be in excess of the petitioner’s needs and not medically necessary. Fla. Admin. Code 59G-1.010(166),- 14F-08282

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying a portion of the petitioner’s request for Personal Care Assistant services was upheld when it was found that the two hours previously approved by the Agency are sufficient to assist the petitioner with his activities of daily living. Additionally, the petitioner’s mother is also available to assist him with these tasks in the morning before work or in the evening after work. Therefore, the Agency’s action was affirmed and the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-01883

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for hours of Adult Companion Care services hours through the Medicaid Long Term Care Waiver program was upheld when the Respondent found that providing the petitioner with personal care services would be in excess of the petitioner’s needs and not medically necessary. Fla. Admin. Code 59G-1.010(166),- 14F-08642

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request to continue his Adult Day Care services hours through the petitioner’s service provider United Healthcare (UHC) was upheld when the denial of ADC services was made by two of the physicians with the Petitioner’s managed care plan and was based on the lack of medical necessity for the services. Therefore, the Department’s action was affirmed and the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-02012

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request to continue his Adult Day Care services hours through the petitioner’s service provider United Healthcare (UHC) was upheld when the petitioner failed to prove the medical necessity of the requested services. Therefore, the Department’s action was affirmed and the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-03547

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying a portion of the petitioner’s request for Personal Care Assistant services was upheld when the Respondent found that the two hours previously approved by the Agency are sufficient to assist the petitioner with her activities of daily living in the afternoon. Therefore, the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-000076

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying a portion of the petitioner’s request for Personal Care Assistant services was upheld when the Respondent found that the evidence and testimony provided during this appeal, the Petitioner has not met his burden of proof of four PCS hours Monday through Friday. Therefore, the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-02530

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying a portion of the petitioner’s request for Personal Care Assistant services was upheld when the evidence indicated a need for some assistance with ADLs, supervision, and a possible need for behavioral services. Medicaid does not provide general supervision to a recipient, only assistance with ADLs.Therefore, the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-00800

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying of a continuation of pediatric extended care services for the certification period was upheld when it was found that the petitioner’s current amount of pediatric extended care service hours were medically necessary. Therefore, the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-02969

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for two Home Health Aide visits seven days a week for the certification period was upheld when the petitioner was observed ambulating without difficulty. Therefore, the Agency’s action was affirmed and the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-03344

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for four hours of personal care services was upheld when it was found that the personal care service hours that the Petitioner requested were in excess of his needs because the assistance with his ADLs can be provided by his parents.Also, it was found that the services provided by caregivers within the home are a less costly alternative to having the Agency provide the services. Therefore, the Agency’s action was affirmed and the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-02014

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of partially denying petitioner’s request for six hours of personal care services per day, Monday through Friday and four hours of PCS on Saturdays and Sunday was upheld when it was found that the personal care service hours that the Petitioner requested were in excess of the petitioner’s needs. Therefore, the Agency’s action was affirmed and the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-03075

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for an additional seven hours a week of personal care services was upheld in part when it was found that the personal care service hours that the Petitioner requested were in excess of his needs. However, the petitioner was approved for three additional hours. Therefore, the appeal was denied in part. Fla. Admin. Code 59G-1.010(166),- 15F-02327

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for four hours a week of personal care services was upheld when it was found that the petitioner’s current amount of personal care service hours were medically necessary. The Agency’s action was affirmed and the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-02530

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for reimbursement of the petitioner’s out-of-pocket expenses made to an in-network pharmacy when that in-network pharmacy failed to bill the managed care plan when it was found that the provider informed the petitioner of his obligations to pay the provider before rendering services. The petitioner was not entitled to reimbursement from a provider that does not bill Medicaid. The Agency’s action was affirmed and the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-02762

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s prescription coverage was upheld when the petitioner does not meet the preauthorization requirements for the approval of Sovaldi or Ribavirin. Therefore, the respondent correctly denied prescription coverage for these drugs. Therefore, the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-05976

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for Glucerna and an increase in personal care hours was upheld when the Petitioner failed to show any evidence of malnutrition or inability to consume regular food.Therefore, the appeal was denied. Fla. Stat.§ 409.979,- 14F-10949

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of reducing the petitioner’s monthly supply of 30′ x 36′ underpads from three cases to two cases and terminating the Petitioner’s approval of dimethicone cream was not upheld when the petitioner’s representative presented evidence that expressed the Petitioner’s need for both the additional 60 underpads per month and dimethicone cream. Therefore, the appeal was granted. Fla. Stat.§ 409.979,-15F-07553

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for issue is the denial of the Petitioner’s request for home modification by a particular contractor was upheld when it was that it was medically necessary for the Petitioner to have bed baths, but it was not medically necessary for the petitioner to have access to the outside yard for showers. Therefore, the appeal was denied. Fla. Stat.§ 409.979,-15F-07812

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for issue is the denial of the Petitioner’s request for adult diapers was determined to be moot when it was found that the Petitioner began receiving the correct diapers on April 23, 2015 and also continued receiving diapers after the August 24, 2015 denial notice. Also, Petitioner’s request for a bathroom modification was denied when the Petitioner failed to show the medical necessity for the higher estimates. Therefore, the appeal was denied. Fla. Stat.§ 409.979,-15F-02618

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for issue is the denial of the Petitioner’s request for adult diapers and underpads was upheld when no testimony or documentation was provided that Medicare had reviewed or approved the medical supplies as well as the monthly amount.Therefore, the appeal was denied. Fla. Stat.§ 409.979,-15F-08045

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for issue is the denial of the Petitioner’s request for medical supplies was upheld when it was found that Vitas was providing hospice services, which includes the monthly medical supplies..Therefore, the appeal was denied. Fla. Stat.§ 409.979,-15F-08207

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for for name brand incontinent supplies was upheld when it was found that that the generic equivalent incontinent supplies are equivalent to the name brand incontinent supplies and that the incontinent supplies offered to the petitioner are sufficient for her needs. Therefore, the appeal was denied. Fla. Stat.§409.979, – 15F-07821, 15F-07822

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for power wheelchair was upheld when it was found that the the petitioner’s physician did not provide a wheelchair evaluation completed by a registered physical or occupational therapist or a certified physiatrist to Better Health and the wheelchair evaluation had not yet been completed at the time of the hearing. Therefore, the appeal was denied. Fla. Stat.§ 409.979,-15F-07369

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for an electrical nerve stimulator (TENS unit) was upheld when it was found that the electrical nerve stimulator, or TENS unit, requested by the Petitioner was not listed as a covered benefit or service in either the DME Handbook or the accompanying fee schedules. Therefore, the appeal was denied. Fla. Stat.§ 409.979,-15F-07844

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for durable medical equipment (DME), specifically a bariatric hospital was upheld when it was found that the the petitioner’s physician did not provide the required documentation. Therefore, the appeal was denied. Fla. Stat.§ 409.979,-15F-07802

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for endodontic treatment in the form of a root canal was upheld because a root canal is not a covered benefit under the petitioner’s plan.Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-06588

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for endodontic treatment in the form of a root canal was upheld when the Petitioner failed to prove medical necessity of the requested procedure.Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-08621

The appellant or authorized representative must exercise the right to appeal within 90 calendar days in all programs. The appeal was requested 236 days following the date of the disputed notice. Therefore, the appeal was dismissed as untimely filed. Fla. Admin. Code 65-2.046-15F-08727

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for endodontic treatment in the form of a root canal was upheld because a root canal is not a covered benefit under the petitioner’s plan.Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-08432

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental procedures was upheld when it was found that the petitioner had not demonstrated the partial denture is medically necessary..Therefore, the appeal was denied. Fla. Stat.§ 409.912,-15F-08114

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental procedures was upheld when it was found that the petitioner had not demonstrated the partial denture is medically necessary..Therefore, the appeal was denied. Fla. Stat.§ 409.912,-15F-08149

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental procedure was upheld when the evidence showed that the requested service was not listed as a covered service.Therefore, the appeal was denied. Fla. Stat.§ 409.912,-15F-07861

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for deny the Petitioner’s request for dental procedure 08660, pre-orthodontic treatment examination to monitor growth and development (braces) was upheld when the Petitioner family to submit the necessary documentation to prove the medical necessity of the procedure. Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-07811

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for the removal of his wisdom teeth was upheld when the evidence failed to show the need for the removal of any of her four wisdom teeth.Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-06746

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for teeth extractions was upheld when the petitioner failed to show that the available surgeons were unwilling or unable to treat her. Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-07557

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for request for extraction of four wisdom teeth and a l.V. sedation was upheld when the evidence showed that the Petitioner’s wisdom teeth could be extracted under a less severe procedure code. Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-07496

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for for orthodontic treatment including braces and monthly treatment visits was upheld when the evidence failed to show the need for general orthodontic treatment. Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-07370

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for for orthodontic treatment including braces and monthly treatment visits was upheld when the evidence showed that the Petitioner needed orthodontic care, but, the petitioner’s needs did not rise to the level necessary (determined by the assessment) for Medicaid to cover the service.Therefore the appeal was denied. Fla. Stat.§ 409.912,-15F-07969

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for certain medical expenses to be paid was upheld when it was found that the petitioner was applying for coverage of expenses incurred before the three month waiting period required before the submission of an application. Therefore the appeal was denied. Fla. Stat.§ 409.912,-15F-8032

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for for orthodontic treatment including braces, fixed appliance theory and monthly treatment visits was upheld when the evidence failed to show the need for the orthodontic treatment. Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-07555

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for the removal of his wisdom teeth was upheld when the petitioner did not provide information documenting the need for the removal of any of his four wisdom teeth and the petitioner’s dentist did not include a narrative explaining the medical necessity for the removal of the wisdom teeth.Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-07364

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental services was upheld when it was found that the requested services were not covered by Medicaid. Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-06731

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental services was upheld when it was found that the requested services were not covered by Medicaid. Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-07669, 15F-08233

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental services was not upheld when it was found that the oral surgery, including surgery to the face or jaw bone is a covered service in the Medicaid adult dental program. Therefore, the appeal was granted. Fla. Stat.§ 409.912,- 15F-08203

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental services was upheld when it was found that the services requested are non-covered services for adults under the Medicaid guidelines referenced above and under the Humana Medicaid dental plan. Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15-07669, 15F-08233

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for a referral to a periodontist was upheld when it was found that the petitioner’s dentist did not provide DentaQuest with the pertinent information it needed to make a decision.Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-06672

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental procedures was upheld when the Respondent provided sufficient testimony that the requested procedures were uncovered and that the Petitioner would have sufficient upper and lower teeth for effective chewing. Therefore, the requested procedure was deemed to not be medically necessary. Fla. Stat.§ 409.912,- 15F-09076

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental procedures was not upheld when it was found that the procedures were medically necessary. Therefore, the appeal was granted. Fla. Stat.§ 409.912,- 15F-07674

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental procedures was upheld when it was found that requested dental procedures were outside the scope of services to which he was entitled to under the benefit plan. Therefore, the requested procedure was deemed to not be medically necessary and the appeal was denied. Fla. Stat.§ 409.912,- 15F-06584

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the Petitioner’s request for dental procedures was upheld when the evidence showed that the resin-based dentures are a more appropriate alternative, and that the Petitioner should explore this option with her provider.Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-05898

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental procedures was upheld when the Respondent provided sufficient testimony that the requested procedures were uncovered and that the Petitioner would have sufficient upper and lower teeth for effective chewing. Therefore, the requested procedure was deemed to not be medically necessary. Fla. Stat.§ 409.912,- 15F-04442

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of terminating a provision of Petitioner’s medical/wound care was not upheld when Sunshine failed to meet its burden. Absent verification that United would cover the seven items at issue, and absent evidence to show that Sunshine diligently attempted to coordinate the disputed care with United, as required by its contract with AHCA, the appeal was granted. Fla. Stat.§ 409.981(1)-15F-05931.

A service is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the petitioner’s request for for Magnetic Resonance Imaging (MRI) scans of the cervical and lumber spine was upheld when the evidence showed that the Petitioner failed to meet the burden. Therefore, the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-06213

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for an increase in his speech therapy services from one hour per week to three hours per week was upheld when the petitioner failed to provide any evidence to support that an increase in his speech therapy services is medically necessary. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-06221

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of partially denying Petitioner’s request for Speech Therapy (ST) service hours was upheld when the petitioner’s speech therapist provided testimony that supported continuing the therapy at the current level.Therefore, the petitioner’s appeal was granted and the petitioner was ordered to continue receiving 13 units of speech therapy services weekly for the current certification period. Fla. Admin. Code 59G-1.010(166),- 15F-07728

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of partially denying Petitioner’s request for outpatient Speech Therapy (ST) services was upheld when the petitioner failed to present authority which allows an administrative hearing officer to lift the $1500.00 outpatient cap. Fla. Admin. Code 59G-1.010(166),- 15F-08326

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for a reduction of the Petitioner’s home health aide services was upheld when the evidence showed that the Petitioner’s primary needs were being addressed in the current one home health aide visit daily. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07034

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of reducing the Petitioner’s home health aide services was not upheld when the evidence showed that there was a permanent change in the daughter’s medical condition. Therefore, the daughter will never be able to resume her role as the petitioner’s primary caretaker. Based on the evidence, the Department found that the Petitioner was in need of additional home health aide and the petitioner’s appeal was granted. Fla. Admin. Code 59G-1.010(166),- 15F-07806

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for additional respite services, companion services, and personal care services under the Long Term Care Program was upheld when it was found that the Petitioner’s needs can be met with the twenty-one hours weekly of in-home assistance which has already been approved by Sunshine. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07047

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for moving services under the Statewide Long Term Managed Care Program was upheld when the Petitioner failed to present authority which justifies approval of the requested services under Medicaid. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-08300

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for moving services under the Statewide Long Term Managed Care Program was upheld when the Petitioner failed to present authority which proved the medical necessity of the requested services. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-08762

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of terminating the petitioner’s respite services was not upheld when it was found there was a caregiver present in the home and the Respondent failed to provide any arguments that showed that the other services in place could provide the care contemplated by the requested services. Therefore, the petitioner’s appeal was granted. Fla. Admin. Code 59G-1.010(166),- 15F-07433

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for an additional 10 hours of long-term care services comprising of any combination of companion services and respite services was not upheld when it was found that the approved services for the petitioner were not adequate to provide her with the care necessary to ensure her health and safety and prevent institutionalization. Therefore, the petitioner’s appeal was granted. Fla. Admin. Code 59G-1.010(166),- 15F-07559

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of reducing petitioner’s personal care services was upheld when the Petitioner failed to show that the current amount of service hours did not meet his needs Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07583

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for 12 companion hours per week through the Statewide Long Term Managed Care Program (LTMC Program) was upheld when it was found that Petitioner does not require either assistance or supervision with activities of daily living. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07092

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying Petitioner’s request for chiropractic visits beyond the allowed 24 visits per year was upheld when it was found that there was not enough evidence in the case to support medical necessity of the requested treatment in compliance with the applicable rules. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07046

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying a portion of the petitioner’s request for personal care services and homemaker services was upheld when the evidence showed that the three hours per day of personal care services and homemaker services approved by the respondent were sufficient to assist petitioner with the activities that may be completed by a personal care assistant or professional homemaker. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07036

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for an additional five hours per week of Personal Care services was upheld when it was found that the approved three hours per day were sufficient to assist the petitioner. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-06732

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for an twelve hours per week of Personal Care services was upheld when it was found that the petitioner did not prove by a preponderance of the evidence that it is medically necessary for him to receive 12 hours of PCS daily. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-08325

was upheld when it was found that the Petitioner’s level of illness did not reach the level of “medically complex” or “medically fragile,”. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07090

was upheld when the evidence failed to show that the Petitioner was dependent upon 24-hour per day medical or nursing care, or that she is dependent upon life-sustaining medical intervention or equipment, such that she would properly be deemed “Medically Complex” or “Medically Fragile.”. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07556

was upheld when the evidence failed to show that requested services were medically necessary. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-08185

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for an additional nine tablets of medicine was upheld when it was found that a request for more than nine tablets would be in excess would exceed the drug limitation nine tablets. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-06972

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for a prescription medication was upheld when it was found that the Petitioner did not meet the age limitation for the drug. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07527

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for a prescription medication was upheld when the Petitioner failed to show the medical necessity of the drug. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07898

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for a prescription medication was upheld when the Petitioner failed to prove the medical necessity of the drug. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07668

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for a prescription medication was upheld when the Petitioner failed to prove the medical necessity of the drug. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-08115

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for replacement Cochlear processor was upheld when it was found that the request for a new processor did not rise to the level of medical necessity under Medicaid law, because repairing the unit or replacing with a refurbished unit would allow the petitioner to hear. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-06587

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action to denying the petitioner’s request to continue receiving Ensure nutritional supplements was upheld when it was found that Petitioner does not require more than three (3) cans per day of Ensure. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07086

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the Petitioner’s request for Lumbar Spine Fusion surgery was not upheld when it was found that there is no equally effective and more conservative or less costly treatment available statewide. Therefore, the petitioner’s appeal was granted. Fla. Admin. Code 59G-1.010(166),- 15F-06691

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the Petitioner’s request for a Bariatric Surgery Procedure was upheld when it was found that the Bariatric Surgery did not meet medical necessity criteria. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07213

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the Petitioner’s request for a thoracic radiofrequency neurolysis was upheld when it was found that the surgery did not meet medical necessity criteria. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-08047

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the Petitioner’s request for a Bariatric Surgery Procedure was upheld when it was found that the records submitted and the Petitioner’s testimony established that she has not been consistently complying with any diet guidelines due to her anxiety issues. Therefore, the petitioner’s appeal was granted. Fla. Admin. Code 59G-1.010(166),- 15F-07847

A service or product is medical necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the Petitioner’s request for pre-operative refractions for cataract surgery was not upheld when it was found that the Petitioner had only utilized one eye exam with refraction within the past 365 days, the plain language of the Optometric Handbook leads the undersigned to conclude that she is entitled to one (1) additional refraction within the 365 day period. Therefore, the petitioner’s appeal was granted. Fla. Admin. Code 59G-1.010(166),- 15F-06745

The appeal was dismissed after the parties filed a Joint Status Report. The parties mutually agreed that the issue was moot. . Fla. Admin. Code 65-2.046- 13F-5476, 13F-5486, 13F-5475, 13F-5477, 13F-5479, 13F-5480, 13F-5483, 13F-5484

The appeal was dismissed when the petitioner’s attorney provided a written statement that indicated that the issue being appealed was resolved and no longer needed a hearing . Fla. Admin. Code 65-2.046- 15F-09795, 15F-09796

The appeal was dismissed when it was found that the Department lacked jurisdiction. Fla. Admin. Code 65-2.046- 15F-10031, 15F-10032

The appeal was dismissed when it was found that the Department lacked jurisdiction. Fla. Admin. Code 65-2.046- 16F-00334, 16F-00802

The appeal was dismissed as abandoned. Fla. Admin. Code 65-2.046- 15F-10578, 16F-00739

A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for retinal scans and related office visits was upheld when the evidence showed that the Petitioner was not apart of the United Healthcare network and the provider did not submit the clinical information requested by United Healthcare. Therefore, the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07582

A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for the prescription medication Harvoni was not upheld when the evidence showed that the petitioner did not meet all of the pre-authorization requirements for the approval of Harvoni. Therefore, the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09074

The denial of the Petitioner’s application for Adult-Related Medicaid was not upheld when it was found that the Department did not complete the state disability determination. Therefore, the appeal was granted and remanded back to the Department to take the corrective action.Fla. Stat. § 409.285, Fla. Stat. § 65-2.056. 15F-09267

The denial of the Petitioner’s application for Medicaid disability was not upheld when it was found that the Petitioner failed to meet the burden of proof. Therefore, the appeal was denied. Fla. Stat. § 409.285, Fla. Stat. § 65-2.056. 16F-04016

A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for bathroom modifications was denied when the Petitioner failed to show the medical necessity for the higher estimates. Therefore, the appeal was denied. Fla. Stat.§ 409.979,-15F-08244

A product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for issue is the denial of the Petitioner’s request for adult diapers, wipes and underpads was upheld when it was found that the requested items were not covered.Therefore, the requested items were not medically necessary and appeal was denied. Fla. Stat.§ 409.979,-15F-09631

A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for Rifton activity chair was upheld when it was found that the the Petitioner did not provide evidence that the Petitioner’s current chair was not meeting his current medical needs. Therefore, the appeal was denied. Fla. Stat.§ 409.979,-15F-08071

A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for curved or swivel stair lift was upheld when it was found that the the Petitioner did not provide evidence of medically necessary. Therefore, the appeal was denied. Fla. Stat.§ 409.979,-15F-10387

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental procedure was upheld when the Petitioner failed to prove medical necessity of the requested procedures.Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-09557

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental procedures was upheld when it was found that the procedures were not covered by Medicaid.Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-08019

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental procedures was upheld when it was found that Medicaid did not cover the requested procedures. Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-09241

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental procedures was upheld when it was found that the procedures did not meet the requirements for medical necessity. Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-09284

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental procedures was upheld when it was found that there was a more appropriate procedures that the Petitioner should explore instead of the requested procedure.Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-09153

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for dental procedures was not upheld when it was found that the Petitioner was experiencing extreme tooth pain to the point of having to take medications .Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-09164

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for orthopedic treatment was upheld when it was found that crowding and pain alone was not sufficient to demonstrate the necessity of orthopedic treatment.Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-09146

The Department’s action to cancel the petitioner’s eligibility for HCBS Medicaid Waiver coverage was remanded in order for the Department to inform the Petitioner of the eligibility requirements and to allow the petitioner to submit the necessary documentation needed for the determination of her application. Therefore, the appeal was granted and remanded to the Respondent in accordance with the order. Fla. Admin Code 59G-4.290, Fla. Admin. Code 59G-4.180- 15F-08155

The Department’s action to deny the petitioner’s application for HCBS Medicaid Waiver coverage was upheld when it was found that the petitioner failed to submit the necessary documentation needed for the determination of the application. Therefore, the appeal was denied. Fla. Admin Code 59G-4.290, Fla. Admin. Code 59G-4.180- 15F-08660

Dental procedures must be prior authorized by Medicaid in order for the surgery to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the petitioner’s request for reimbursement of $5400.00 for dental procedures was dismissed when it was found that jurisdiction did not exist . Therefore, the appeal was dismissed. Fla. Admin. Code 59G-1.010(166),- 15F-08757

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for teeth extractions was upheld when it was found that the procedure was not medically necessary. Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-09709

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for orthodontic
treatment including braces was upheld when the evidence showed that the requested services were not medically necessary. Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-09433

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for orthodontic
treatment including braces was upheld when the evidence showed that the requested services were not medically necessary. Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-09775, 15F-09922

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Agency’s action of denying the petitioner’s request for orthodontic
treatment including braces was upheld when the evidence showed that the requested services were not medically necessary. Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-09675

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for the removal of his wisdom teeth and I.V. sedation was not upheld when it was found that the requested procedures were medically necessary.Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-09410

Dental procedures must be prior authorized by Medicaid in order for a dental procedure to be deemed medically necessary. A service is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the Petitioner’s request for a second set for dentures when it was found that the Petitioner could undergo alternative, less expensive procedures.Therefore, the appeal was denied. Fla. Stat.§ 409.912,- 15F-08821

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the petitioner’s request for a Magnetic Resonance Imaging (MRI) scans was upheld when the evidence showed that the Petitioner failed to meet the burden of medical necessity. Therefore, the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09886

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to deny the petitioner’s request for epidural steroid injections was upheld when the evidence showed that the Petitioner failed to meet the burden of medical necessity. Therefore, the appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09958

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for additional respite services, companion services, and personal care services under the Long Term Care Program was upheld when it was found that the Petitioner does not have a constant need for medical care. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-07619

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for moisturizer, soaps and creams was upheld when it was found that the requested items were not covered under the Petitioner’s medical plan. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09437

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for Personal Emergency Response System was upheld when it was found that the system was not medically necessary for the Petitioner. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09438

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for additional personal care services, companion services, and homemaker services was upheld when it was found that the Petitioner does not have a constant need for medical care. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-08247

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for additional personal care services was upheld when it was found that the additional hours are in excess of the Petitioner’s needs. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-08960

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for additional personal care services was upheld when it was found that personal hours were not medically necessary. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09813

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for a custom cranial remolding helmet was upheld when it was found that the Petitioner would not benefit from the requested product . Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09253

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for a wearable cardioverter defibrillator was upheld when it was found that the requested product was not medically necessary . Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09843

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for homemaker, companion and additional respite and personal care services under the Statewide Long Term Managed Care Program was upheld when the Petitioner failed to present authority which proved the medical necessity of the requested services. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09325

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for homemaker, companion and additional respite and personal care services under the Statewide Long Term Managed Care Program was upheld when the Petitioner failed to present authority which proved the medical necessity of the requested services. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09493

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for disposable liners and additional personal care services was upheld when it was found that the additional hours were not medically necessary. Also, the disposable liners were found to not be ripe for appeal because the request for products require prior authorization. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09071, 15F-09818

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for two additional personal care services five days a week was upheld when it was found that the current amount of personal care and homemaker services are sufficient to meet the Petitioner’s needs. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09374

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for occupational therapy services was upheld when it was found that the additional hours were not medically necessary for the Petitioner. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09393

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of reducing the Petitioner’s occupational therapy was upheld when it was found that the petitioner’s original level of occupational therapy was in excess of her needs. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-08633

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of reducing the Petitioner’s occupational therapy was not upheld when it was found that the therapy reports showed that the Petitioner was in need of occupational therapy. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09869

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of denying the petitioner’s request for an additional hour of companion services was upheld when it was found that the Petitioner’s current amount of services were sufficient for meeting her medical needs does not have a constant need for medical care. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-08528

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action of terminating the Petitioner’s Dexcom Continuous Glucose Monitor not upheld when it was found that the Respondent failed to meet the burden of proof. Therefore, the petitioner’s appeal was granted. Fla. Admin. Code 59G-1.010(166),- 15F-08555

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to terminate the Petitioner’s Prescribed Pediatric Extended Care Services (“PPEC”) was upheld when it was found that the Petitioner’s level of illness did not reach the level of “medically complex” or “medically fragile,”. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09525

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to terminate the Petitioner’s Prescribed Pediatric Extended Care Services (“PPEC”) was upheld when the evidence failed to show that requested services were medically necessary because the Petitioner did not need continuous nursing care. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-08008

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to terminate the Petitioner’s Prescribed Pediatric Extended Care Services (“PPEC”) was upheld when the evidence failed to show that requested services were medically necessary because the Petitioner failed to prove the medical necessity of the requested services. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-09066

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to terminate the Petitioner’s Prescribed Pediatric Extended Care Services (“PPEC”) was upheld when the evidence failed to show that requested services were medically necessary because the Petitioner did not need continuous nursing care. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-08264

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for a prescription medication was upheld when the Petitioner failed to show the medical necessity of the drug. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 15F-08823

A service or product is medically necessary when it meets an individual’s needs in the most appropriate and conservative manner possible. The Department’s action to denying the petitioner’s request for prescription medication was upheld when it was found that the medication was not medically necessary. Therefore, the petitioner’s appeal was denied. Fla. Admin. Code 59G-1.010(166),- 16F-00490, 16F-00491

Out of State Medicaid Reimbursement

The Department’s decision to deny the Petitioner’s request for payment of out-of-state medical expenses incurred as the result of an emergency was upheld when the Petitioner submitted account statements indicating that the charges for medical services had been reversed instead of submitting claims for payment. An out of state provider must submit a claim for emergency services to the Florida Medicaid fiscal agent in order to be reimbursed for payment. Fla. Admin. Code R. 59G-5.020,-14F-0240

SSI-Related Benefits

The Department’s action to deny the petitioner’s application for SSI-Related Emergency for Medicaid for Alien benefits on the basis that the Petitioner did not meet the disability requirement was reversed when the petitioner provided evidence that she did meet the disability requirements for the program. The petitioner provided psychiatric, psychological and physical functional capacity evaluations that were not originally provided to the Division of Disability Determination. Each evaluation described the Petitioner’s inability to perform numerous daily activities. Fla. Admin. Code R. 65A-1.710.-13F-11610

The Department’s action to deny the petitioner’s application for SSI-Related Emergency for Medicaid for Alien benefits on the basis that the Petitioner did not meet the disability requirement was upheld when the evidence presented showed that the petitioner did not have any impairment different from or in addition to those that were reported to SSA. Accordingly, the decision made by SSA is controlling because the respondent is required by law to adopt any decision made by the SSA within the last year unless the application is claiming a new condition not previously reviewed by SSA. Fla. Admin. Code R. 65A-1.710.-14F-5279

The Department’s action to deny emergency coverage for an undocumented non-citizen was dismissed due to the lack of jurisdiction in this matter. The petitioner had no substantial interest in whether in whether Medicaid pays for a service that was received. No legal authorit can be found showing the undersigned has jurisdiction regarding payment issues. Fla. Admin. Code R. 65A-1.710.-14F-5021

In order to receive SSI-Related Emergency for Medicaid for Alien benefits, an applicant must meet the disability requirement, which states that the applicant must be unemployed and not engaging in substantial gainful activity and the impairment must last or be expected to last for a continuous period of at least 12 months. The Department’s action to deny the petitioner’s application for SSI-Related Emergency for Medicaid for Alien benefits on the basis that the Petitioner did not meet the disability requirement was upheld when the petitioner failed to provide evidence that proved that his impairment was going to last for at least 12 months. Fla. Admin. Code R. 65A-1.710-13F-12017

In order to receive SSI-Related Emergency for Medicaid for Alien benefits, an applicant must meet the disability requirement, which states that the applicant must be unemployed and not engaging in substantial gainful activity and the impairment must last or be expected to last for a continuous period of at least 12 months. The Department’s action to deny the petitioner’s application for SSI-Related Emergency for Medicaid for Alien benefits was upheld when the DDD determined that the Petitioner was not disabled at two of the five steps of the evaluation process because his impairments were found to be not severe. Fla. Admin. Code R. 65A-1.710-14F-2178

In order to receive SSI-Related Medicaid benefits, an applicant must meet the disability requirement, which states that the applicant must be unemployed and not engaging in substantial gainful activity and the impairment must last or be expected to last for a continuous period of at least 12 months. The Department’s action to deny the petitioner’s application for SSI-Related Medicaid benefits was upheld when the DDD determined that the Petitioner was not disabled at step five of the evaluation process because his impairments were found to not preclude him from working in the national economy. Fla. Admin. Code R. 65A-1.710-14F-2193

In order to receive SSI-Related Medicaid benefits, an applicant must meet the disability requirement, which states that the applicant must be unemployed and not engaging in substantial gainful activity and the impairment must last or be expected to last for a continuous period of at least 12 months. The Department’s action to deny the petitioner’s application for Adult Related Medicaid was not upheld when the Department concluded that all of the petitioner’s disabling conditions were not reviewed by the SSA. The new condition developed before the Medicaid application, therefore, the adoption of SSA’s unfavorable disability decision was not correct. Fla. Admin. Code R. 65-2.060-14F-2705

In order to receive SSI-Related Medicaid benefits, an applicant must meet the disability requirement, which states that the applicant must be unemployed and not engaging in substantial gainful activity and the impairment must last or be expected to last for a continuous period of at least 12 months. The Department’s action to deny the petitioner’s application for SSI-Related Medicaid benefits was not upheld when more than a year passed since the SSA’s last denial decision. Therefore, the Department was no longer bound by SSA’s denial decision. Department policy states that it is required to make an independent disability determination when more than a year passed since SSA’s decision. Fla. Admin. Code R. 65-2.060-14F-3005

In order to receive SSI-Related Medicaid benefits, an applicant must meet the disability requirement, which states that the applicant must be unemployed and not engaging in substantial gainful activity and the impairment must last or be expected to last for a continuous period of at least 12 months. The Department’s action to deny the petitioner’s application for SSI-Related Medicaid benefits was upheld when the petitioner failed to meet the required burden of proof. The Department found that while petitioner may have some medically determinable impairments, these impairments should not preclude him from performing other work in the national economy, specifically light and sedentary exertional activity jobs. The undersigned concludes Petitioner is found not disabled at step-five, in accordance with the objective medical evidence. Fla. Admin. Code R. 65-2.060(1), 65A-1.710-14F-3020

In order to receive SSI-Related Medicaid benefits, an applicant must meet the disability requirement, which states that the applicant must be unemployed and not engaging in substantial gainful activity and the impairment must last or be expected to last for a continuous period of at least 12 months. The Department’s action to deny the petitioner’s application for Adult Related Medicaid was not upheld when the Department concluded that all of the petitioner’s disabling conditions were not reviewed by the SSA. The new condition developed before the Medicaid application, therefore, the adoption of SSA’s unfavorable disability decision was not correct. Fla. Admin. Code R. 65-2.060-14F-2705

In order to receive SSI-Related Medicaid benefits, an applicant must meet the disability requirement, which states that the applicant must be unemployed and not engaging in substantial gainful activity and the impairment must last or be expected to last for a continuous period of at least 12 months. The Department’s action to deny the petitioner’s application for SSI-Related Medicaid was upheld when the Petitioner failed to meet the required burden of proof. The Petitioner did not have medically determinable impairments, the medical evidence suggested theses impairments were not expected to last 12 months or more in accordance with the statutory guidelines. Therefore, the denial of Medicaid benefits was appropriate. Fla. Admin. Code R. 65-2.060-14F-3266

In order to receive SSI-Related Medicaid benefits, an applicant must meet the disability requirement, which states that the applicant must be unemployed and not engaging in substantial gainful activity and the impairment must last or be expected to last for a continuous period of at least 12 months. The Department’s action to deny the petitioner’s application for SSI-Related Medicaid was upheld when the Petitioner failed to meet the disability requirement. The Petitioner showed no evidence of disabling conditions and the Petitioner does not meet the age requirement. Therefore, the Department correctly denied the Medicaid application. Fla. Admin. Code R. 65-2.060-14F-3292

Medicaid Overpayment

The petitioner submitted an application for Emergency Medicaid for Aliens (EMA) benefits. The petitioner had no Immigration and Naturalization status and did not provide any verification of his current income. The Department was unable Therefore, the department’s action of denying the Petitioner’s application was upheld. 7 C.F.R. § 273.2(c)(5)- 14F-10544

The Department’s action to establish an overpayment of $200 in Food Assistance Benefits was upheld where the agency failed to update the Petitioner’s UCB. Therefore, the Department’s action was affirmed and the Department may seek repayment of FAP benefits. Admin. Code 65A-1.900(1)(b), Fla. Stat. ch. 414.41(1)(2)- 15F-08021

Termination of Benefits

The Department has 10 days in which to process a change after it receives notification of change. If the change is adverse to the interests of the beneficiary, the change is effective “the first day of the next month the change can be made allowing for 10 § days adverse action notice.” In the present case, the Department first received notice of the petitioner’s departure from the State and her request to terminate Medicaid § coverage on June 30, 2014. The Department had 10 days to process the change. Pursuant to this regulation, the petitioner’s Medicaid coverage should have terminated effective August 1, 2014, not September 30, 2014 as the Notice of Case Action indicates. Fla. Admin. Code R. 65-2.044.-14F-08896

The Department has 10 days in which to process a change after it receives notification of change. If the change is adverse to the interests of the beneficiary, the change is effective “the first day of the next month the change can be made allowing for 10 days adverse action notice.” In the present case, the Department first received notice of the petitioner’s departure from the State and her request to terminate Medicaid coverage on June 30, 2014. The Department had 10 days to process the change. Pursuant to this regulation, the petitioner’s Medicaid coverage should have terminated effective August 1, 2014, not September 30, 2014 as the Notice of Case Action indicates. Fla. Admin. Code R. 65-2.044.-15F-00013

Disability Requirement

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. § Here, the Agency denied the Petitioner’s application for Adult Related Medicaid due to not meeting the disability requirement. The evidence presented by the Petitioner showed that the Petitioner can be gainfully employed at sedentary work. Therefore, the denial is granted and the denial was reversed and Medicaid was approved, a disability review date of one year from the decision is to be established. Therefore, the petitioner’s application for Medicaid benefits was denied. – Fla. Admin. Code, § 65A-1.710-14F-09284,14F-09285

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. § The Department’s action of denying the Petitioner’s application for benefits or Medicaid was upheld when the petitioner failed to meet the requirements for medicaid because the petitioner does not meet the age and disability requirement. Therefore, the petitioner’s application for Medicaid benefits was denied. – Fla. Admin. Code, § 65A-1.710-14F-09718

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of denying the Petitioner’s application for TCA benefits or Medicaid was upheld when the hearing officer concluded that the issue was moot because the petitioner does not have a minor child. Therefore, the petitioner did not meet the required burden of proof and the appeal was denied.- Fla. Admin. Code, § 65A-1.710-14F-08828, 14F-09516

The petitioner wished to disenroll from Sunshine health maintenance organization and enroll in another health plan. The Respondent § allows plan participants to disenroll after the initial period for good cause. Good cause includes unreasonable delay or denial of service. The evidence showed that the petitioner suffers from severe asthma that frequently requires immediate medical attention. During a recent asthmatic episode, the petitioner had to wait two weeks for an appointment, placing her at risk of permanent health damage. Therefore, the Department concluded that the petitioner has a good cause reason to change HMOs and the Petitioner’s appeal was granted.- Fla. Stat., § 409.969(2)-14F-09483

The petitioner wished to enroll in another health plan. The Respondent § allows plan participants to disenroll after the initial period for good cause. Good cause includes unreasonable delay or denial of service. The evidence lacked any proof that the petitioner received poor quality of care, lack of access to necessary specialty services, an unreasonable delay or denial of service or fraudulent enrollment. Therefore, the Department concluded that the petitioner did not establish a good cause that would allow the petitioner change health plans- Fla. Stat., § 409.969(2)-15F-00022

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of denying the Petitioner’s application for TCA benefits or Medicaid was upheld when the hearing officer concluded that the issue was moot because the petitioner does not have a minor child. Therefore, the petitioner did not meet the required burden of proof and the appeal was denied.- Fla. Admin. Code, § 65A-1.710-14F-08828, 14F-09516

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The income limit for full Medicaid benefits for a household of two is $241.00. The petitioner’s countable unearned income of $752.00 exceeds the full Medicaid limit. Therefore, the Petitioner was eligible for the Medically Needy program and the Department correctly enrolled the Petitioner in the Medically Needy program.. Fla. Admin. Code, § 65A-1.710-14F-09310

The Food Assistance Program and Special Low-Income Medicare Beneficiary require proof of Florida residency. § The respondent argued that the petitioner proved Florida residency. The discrepancy was resolved and the petitioner’s appeal was granted. Fla. Admin. Code, § 65A-1.205 – 14F-08529, 14F-08530

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Food Assistance Program and Special Low-Income Medicare Beneficiary program are benefits that are received through Medicaid. The Department’s action of denying tHE Petitioner’s application for Adult Related Medicaid and the Food Assistance program was reversed when the evidence showed that the Petitioner was unable to perform any work in the national economy. Admin. Code, § 65A-1.710. 14F-09284, 14F-09285

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The petitioner asserted that the Respondent delayed in processing his Medicaid Program applications. The evidence provided showed that the petitioner provided the requested verification partly in October 2014, November 2014 and the remainder of the verification partly in December 2014. The respondent could not authorize the August 2014 SSI-Related Medicaid Program benefits until December 2014. Therefore, it is concluded that the delay of the approval of SSI-Related Medicaid Program benefits effective August 2014 was not caused by the respondent and the applications. Admin. Code, § 65A-1.710. 14F-09375

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The authority states that if SSA has denied disability within one year, or if the denial is under appeal, the SSA decision is to be adopted. The evidence shows that a full year has not lapsed since the SSA denied the petitioner’s application for Medicaid, as the denial took place on May 9, 2014. Therefore, the Agency’s action of denying the petitioner Medicaid benefits was upheld. Fla. Admin. Code, § 65A-1.710 14F-8439

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act.It is concluded that the Respondent’s action to deny the petitioner’s application for SSI related Medicaid Program benefits was within the rules. However the hearing officer explored all other Medicaid Program benefits, like Family-Related Medicaid Program. The Petitioner did not meet the criteria for Family-Related Medicaid Program benefits. It is concluded, the Respondent’s action to deny the petitioner’s application for Medicaid Program benefits was upheld when the evidence showed that the Petitioner did not have a minor child residing with her. Fla. Admin. Code, § 65A-1.710- 15F-01117

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act.It is concluded that the Respondent’s action to deny the petitioner’s application for SSI related Medicaid Program benefits was within the rules. However the hearing officer explored all other Medicaid Program benefits, like Family-Related Medicaid Program. The Petitioner did not meet the criteria for Family-Related Medicaid Program benefits. It is concluded, the Respondent’s action to deny the petitioner’s application for Medicaid Program benefits was upheld when the evidence showed that the Petitioner did not have a minor child residing with her. Fla. Admin. Code, § 65A-1.710- 15F-01328

To be eligible for Medicaid Waiver–Home and Community Based Services the petitioner must have a monthly income cannot exceed $2,199.00 for an individual. Since petitioner’s monthly income exceeded the income limit, he is required to establish and fund a Qualified Income Trust. The petitioner’s income exceeded the income and did not provide verification that an Income Trust was established or that there was any change in the petitioner’s monthly income. Therefore, the Petitioner’s application was denied and the appeal was denied. Fla. Admin. Code,§ 65A-1.710- 15F-01271

The Medicaid benefits were not authorized because the respondent denied the petitioner’s benefits due to the petitioner’s failure to meet the disability requirement. The petitioner’s representative asserted that the Social Security approved the petitioner’s disability. The appeal is denied in that the petitioner and his wife do not meet the disability criteria. Fla. Admin. Code, § 65A-1.710- 14F-11024

The Medicaid benefits were not authorized because the respondent denied the petitioner’s benefits due to the petitioner’s failure to meet the disability requirement. The petitioner’s representative asserted that the Social Security approved the petitioner’s disability. The appeal is denied in that the petitioner did not meet the disability criteria. Fla. Admin. Code, § 65A-1.710- 15F-01070

To be eligible for Medicaid benefits the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The case was remanded because upon review, the undersigned concluded that the Respondent incorrectly denied the petitioner’s Medicaid application without giving her adequate written notice of the form missing the complete the process. Fla. Admin. Code, § 65A-1.710-15F-00203

To be eligible for Medicaid benefits the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The case is remanded to be respondent for a disability determination. . Fla. Admin. Code, § 65A-1.710-15F-00537

The Medicaid benefits were not authorized because the respondent denied the petitioner’s benefits due to the petitioner’s because the income exceeds the income standard of $303 for full Medicaid for the adults. The Respondent concludes the petitioner does not qualify for full Medicaid for himself and his wife in Family-track Medicaid. The appeal is denied and the Respondent correctly enrolled the Petitioner and his into the Family-Track Medically Needy Program. Fla. Admin. Code, § 65A-1.710- 15F-00176,15F-00177

The Department’s denial of the Petitioner’s application for Medicaid, FAP and TCA benefits was upheld when The petitioner did not meet all required conditions of eligibility for FAP benefits, Medicaid benefits or for TCA benefits. She has not provided evidence she cured the CSE and QC sanctions. Therefore, she has not met her burden to proof. Fla. Admin. Code, § 65A-1.710- 14F-09672, 14F-10584, 14F-10865

To be eligible for Special Low Income Medicaid Part B, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The petitioner’s countable unearned income exceeds the income standards for the program. Therefore, the Petitioner was eligible for the Medically Needy program and the Department correctly enrolled the Petitioner in the Medically Needy program.. Fla. Admin. Code, § 65A-1.710-15F-00926

The petitioner submitted an application for Emergency Medicaid for Aliens (EMA) benefits for her newborn.The petitioner has the right to have eligibility determined for the newborn. The Department agreed to determine eligibility for the newborn; however, no evidence was presented to show coverage for the newborn beyond the birth month. The appeal is denied in part as EMA benefits for the petitioner for the dates of service requested and Medicaid for the newborn for the month of birth has been provided. These issues were determined to be moot. 7 C.F.R. § 273.2(c)(5)- 15F-00115

To be eligible for Special Low Income Medicaid Part B, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department concluded that if the Department erred in failing to remind Petitioner of his right to a fair hearing, such error was ultimately harmless. Therefore, the appeal was denied. Fla. Admin. Code, § 65A-1.710-15F-00013

To be eligible for Special Low Income Medicaid Part B, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The petitioner’s countable unearned income exceeds the income standards for the program. Therefore, the Petitioner’s appeal was denied and the Agency’s action was upheld. Fla. Admin. Code, § 65A-1.710-14F-10839

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The petitioner would like to change managed health plans. The cited authority explains Medicaid recipients can change managed care plans within 90 days of enrollment and during the annual open enrollment. The issue is not yet ripe for an appeal is petitioner is within the time period to change to different HMO. The issues presented under appeal are non-jurisdictional and not ripe. Fla. Admin. Code, § 65A-1.710-14F-10962

To be eligible for Food Assistance and Temporary Cash Assistance Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Petitioner did not provide the necessary documentation. Therefore, the department’s action of denying the petitioner’s request for Medicaid benefits was upheld. Fla. Admin. Code, § 65A-1.710-15F-02120, 15F-02121, 15F-02157

To be eligible for Food Assistance and Temporary Cash Assistance Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The petitioner’s countable income was $1458.95 which exceeds the income limit for an individual in the SLMB and QI 1 programs. Therefore, the undersigned concludes that the Department correctly terminated SLMB program benefits and subsequently denied QI 1 program benefits. Therefore, the Petitioner’s share of cost increased and the respondent’s calculation was upheld. Fla. Admin. Code, § 65A-1.710-15F-01715, 15F-04768, 15F-04769

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Respondent’s action of retaining enrollment in Medically Needy Program with monthly share of cost amounts was upheld in part because the petitioner was able to meet the burden of proof for the January 2015. Based on the review of the evidence, the petitioner’s appeal for a lower share of cost amount for December 2014 and for February 2015 and was denied. Also, the petitioner’s appeal for a lower share of cost amount for January 2015 is granted and the lower share of cost is to commence. Fla. Admin. Code, § 65A-1.710-15F-00296

The Respondent’s action of denying the Respondent’s request to change Managed Care Plans upheld when the undersigned concluded that the petitioner met the good cause exemption of “unreasonable delay”. Therefore the Respondent’s action was affirmed and the appeal was granted . Fla. Admin. Code,§ 65A-1.710 – 15F-03212

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of denying the Petitioner’s application for Medicaid was upheld when it was found that the Petitioner was under the age of 65, and did not meet the criteria for SSA-Related Medicaid coverage.Therefore, the department’s action of denying the Petitioner’s application for Medicaid was upheld and the appeal was denied. Fla. Admin. Code, §65A-1.710-15F-07667

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of denying the Petitioner’s application for Medicaid was upheld when it was found that the Petitioner was under the age of 65, and did not meet the disability criteria for SSA-Related Medicaid coverage.Therefore, the department’s action of denying the Petitioner’s application for Medicaid was upheld and the appeal was denied. Fla. Admin. Code, §65A-1.710-15F-08068

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of denying the Petitioner’s application for Medicaid was upheld when it was found that the Petitioner failed to submit her worsened and new medical condition documents to the SSA.Therefore, the department’s action of denying the Petitioner’s application for Medicaid was upheld and the appeal was denied. Fla. Admin. Code, §65A-1.710-15F-08302

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of denying the Petitioner’s application for Medicaid was upheld when it was found that the Petitioner did not indicate that he has a different or new medical condition that the SSA is unaware of.Therefore, the department’s action of denying the Petitioner’s application for Medicaid was upheld and the appeal was denied. Fla. Admin. Code, §65A-1.710-15F-08127

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of terminating the Petitioner’s Medicaid benefits was upheld when it was found that the respondent could not explain the reason DDD determined that the petitioner was no longer disabled.Therefore, the department’s action of denying the Petitioner’s application for Medicaid was not upheld and the appeal was granted. Fla. Admin. Code, §65A-1.710-15F-08193

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of denying the Petitioner’s application for Medicaid was upheld when it was found that the Petitioner did not indicate that he has a different or new medical condition that the SSA is unaware of. Therefore, the department’s action of denying the Petitioner’s application for Medicaid was upheld and the appeal was denied. Fla. Admin. Code, §65A-1.710-15F-08078

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of denying the Petitioner’s application for Medicaid was not upheld when it was found that the respondent incorrectly denied the Medicaid application as the petitioner was separated from her husband and can be considered a household of one. Therefore, the appeal was partially granted and the case was remanded. Fla. Admin. Code, §65A-1.710-15F-07787

Therefore, the department’s action was not upheld and the appeal was granted. Fla. Admin. Code, §65A-1.710-15F-07745,15F-7746

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of decreasing the Petitioner’s Food Assistance benefits, enrolling the Petitioner into the Medically Needy program and terminating the Petitioner’s wife’s Medicaid benefits was upheld when it was found that the petitioner’s countable income exceeded the income limit for full Medicaid and Food Assistance. Also, Petitioner’s petitioner’s wife did not meet the technical requirement to receive Medicaid benefits under the Family-Related Medicaid program. Therefore, the appeal was denied. Fla. Admin. Code, §65A-1.710-15F-07159,15F-07357

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of enrolling the Petitioner into the Medically Needy program with a share of cost was partially when it was found that the petitioner’s countable income exceeded the income limit for full Medicaid. Therefore, Denied in that petitioner’s household is not eligible for FA benefits and petitioner’s wife is not eligible for full Family-Related Medicaid. And partially granted in that petitioner’s wife’s SOC is reduced from $666 to $468.. Fla. Admin. Code, §65A-1.710-15F-08877, 15F-09482

To be eligible for Food Assistance, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action was upheld when it was found that the petitioner was still waiting asylum status approval. Therefore, the petitioner’s household did not have a qualified alien and the appeal was denied. Fla. Admin. Code, §65A-1.710-15F-08094, 15F-08254

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of enrolling the Petitioner into the Medically Needy program with a share of cost was partially upheld. The appeal relating to the eligibility for full Medicaid benefits and the subsequent enrollment into the Medically Needy Program with a monthly share of cost of $1, 750 and the denial of MSP benefits, was denied. However, the appeal for Medicaid/Medically Needy benefits and the MSP benefits beginning in April 2015, is granted and remanded in accordance with the Conclusion of Law, in order to allow the respondent to complete the retroactive Medicaid eligibility determination. Fla. Admin. Code, §65A-1.710-15F-08320, 15F-10224

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of denying the Petitioner for Institutional Care Program (ICP) benefits program was not upheld when it was found that the petitioner’s nursing home placement was appropriate and that the Petitioner is eligible for ICP Medicaid. Therefore, the appeal was granted and the Department is ordered to take corrective action within 10 days from the date of this order. Fla. Admin. Code, §65A-1.710- 15F-07798

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of enrolling the Petitioner and her husband into the Medically Needy program with a share of cost and decision to deny the Petitioner and her husband request for Medicare Savings Program was upheld when it was found that the petitioner and her husband’s total income exceeded the highest possible income for full Medicaid and all three Medicare Savings Programs. Therefore, the appeal was denied. Fla. Admin. Code, §65A-1.710 (30) –15F-06480, 15F-06481

the petitioner an opportunity to verify that the petitioner’s son resided with him at the time of application.Therefore, the appeal was granted. Fla. Admin. Code, §65A-1.710 (30) –15F-7050, 15F-7097, 15F-7098

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Petitioner’s appeal to change the amount of Food Assistance benefits and Qualified Medicare Beneficiaries (QMB) Program benefits was denied when it was found that the Petitioner was receiving the maximum allotment of FAP benefits and ineligible to receive retroactive Medicaid benefits for the three months prior to the month of application. Therefore, the appeal was denied. Fla. Admin. Code, §65A-1.710 (30) –15F-07241, 15F-07284

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Petitioner’s appeal to change the amount of Food Assistance benefits was The FAP appeal (15F-08836) is granted and remanded back to the respondent to take corrective action as specified in the Conclusions of Law. And the Medicaid appeal (15F-08938) is dismissed as non-jurisdictional. Therefore, the appeal was denied. Fla. Admin. Code, §65A-1.710 (30) –15F-08836, 15F-08938

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s decision to deny the petitioner’s application for SSI-Related Medicaid benefits on the basis that he did not meet the disability requirements of the program was upheld when it was found that the Petitioner did not meet the disability requirements for the program. Therefore, the appeal was denied. Fla. Admin. Code, §65A-1.710 (30) –15F-07638

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s decision to deny the petitioner’s application for SSI-Related Medicaid benefits on the basis that he did not meet the disability requirements of the program was upheld when it was found that the Petitioner did not meet the disability requirements for the program. Therefore, the appeal was denied. Fla. Admin. Code, §65A-1.710 (30) –15F-07639

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s decision to deny the petitioner’s application for SSI-Related Medicaid benefits on the basis that he did not meet the disability requirements of the program was upheld when it was found that the Petitioner did not meet the disability requirements for the program. Therefore, the appeal was denied. Fla. Admin. Code, §65A-1.710 (30) –15F-07992

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s decision to deny the petitioner’s application for SSI-Related Medicaid benefits on the basis that he did not meet the disability requirements of the program was upheld when it was found that the Petitioner did not meet the disability requirements for the program. Therefore, the appeal was denied. Fla. Admin. Code, §65A-1.710 (30) –15F-08026

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s decision to deny the Petitioner and his wife for Medicare/Medicare Buy-In application was upheld when it was found that the Petitioner’s income exceed the limits of the program. Also, the Petitioner was found to be ineligible for the Ql1 Buy-In because the Petitioner’s income exceeded the income standard for the program.Therefore, the appeal was denied. Fla. Admin. Code, §65A-1.710 (30) –15F-07623, 15F-09629

upheld when it was found that the petitioner’s total income exceeds the highest possible income for full Medicaid and Temporary Cash Assistance. Therefore, the appeal was denied. Fla. Admin. Code, §65A-1.710 (30) –15F-05419, 15F-05420,15F-05479, 15F-05480

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of enrolling the Petitioner into the Medically Needy program with a share of cost and decision to deny the Petitioner’s request for Temporary Cash Assistance and SSI-Related benefits was upheld when it was found that the petitioner was not disabled. Therefore, the appeal was denied. Fla. Admin. Code, §65A-1.710 (30) –15F-08268, 15F-08269

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of denying the Petitioner’s application for Medicaid was upheld when it was found that the Petitioner was under the age of 65, and did not meet the criteria for SSA-Related Medicaid coverage.Therefore, the department’s action of denying the Petitioner’s application for Medicaid was upheld and the appeal was denied. Fla. Admin. Code, §65A-1.710-15F-08793

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s decision to deny the petitioner’s application for SSI-Related Medicaid benefits was not upheld when it was found that the Department failed to include a retroactive month from the Petitioner’s previous application. Therefore, the appeal was granted and remanded to the Department for a determination of eligibility. Fla. Admin. Code, §65A-1.710 (30) -15F-08957

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of denying the Petitioner for Institutional Care Program (ICP) benefits program was not upheld when it was found that the requirements for an increase in the spousal diversion amount. Therefore, the appeal was granted and the Department is ordered to take corrective action within 10 days from the date of this order. Fla. Admin. Code, §65A-1.710- 15F-07641

The appeal was dismissed when the petitioner requested to withdraw his Food Assistance Program and Q1 appeal. The petitioner had no other issues that needed to be addressed. Therefore, the appeals were dismissed. Fla. Admin. Code, §65A-1.710-15F-08886, 15F-08887

The Department’s action of closing the petitioner’s case for Food Assistance Program and Medicaid benefits was not upheld when the Department agreed to reestablish the Petitioner’s benefits for FAP and Medicaid. Therefore, the matters were resolved and the appeal was dismissed as moot. Fla. Admin. Code, §65A-1.710- 15F-09101, 15F-09102

The Department’s action of terminating the Petitioner’s Qualifying Individuals was upheld when it was found that the Petitioner’s income exceeded the limits of the program. Also, the Department’s action of rescheduling the start date of the Petitioner’s Food Assistance benefits was not upheld when it was found that the Department failed to open the Petitioner’s application for FAP benefits her application.. Therefore, the appeal was denied. Fla. Admin. Code, §65A-1.710- 15F-09398, 16F-00149

The Department’s action of denying the Petitioner’s application for Qualifying Individuals was upheld when it was found that the Petitioner’s income exceeded the limits of the program. Therefore, the appeal was denied. Fla. Admin. Code, §65A-1.710- 15F-09761

The Department’s action of terminating the Petitioner’s Qualifying Individuals was upheld when it was found that the Petitioner’s income exceeded the limits of the program. Also, the Department’s action of denying the Petitioner’s application Food Assistance benefits was upheld when it was found that the the Petitioner’s income exceeded the limits of the program. Therefore, the appeal was denied. Fla. Admin. Code, §65A-1.710- 15F-09767, 15F-09768

To be eligible for Food Assistance, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action was upheld when it was found that the petitioner was a 5-year ban due to the fact that she is a Legal Permanent Resident. Therefore, the petitioner is not currently eligible for Food Assistance benefits and the appeal was denied. Fla. Admin. Code, §65A-1.710-15F-09549, 15F-09550

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of terminated petitioner’s SSl-Related Medically Needy (MN) Share of Cost (SOC) and Qualified Medicare Beneficiary (QMB) Medicaid benefits was not upheld when it was found that the Department did not correctly evaluate the Petitioner’s application. Therefore, the appeal was remanded to the respondent for corrective action. Fla. Admin. Code R. 65A-1.710(5).710-15F-9029

To be eligible for SSI-Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Department’s action of denying the petitioner’s application for Temporary Cash Assistance, Medicaid and Food Assistance Program benefits was granted and remanded when it was found that the Department failed to notify the Petitioner of the missing documentation needed for the determination of the application. Fla. Admin. Code, §65A-1.710 (30) -15F-09809, 15F-09810, 15F-09811

To be eligible for SSI- Related Medicaid, the petitioner either been deemed disabled or over the age of 65. For an individual who does not have custody of minor children, in not pregnant, and is less than 65 years of age, to receive benefits he or she must meet the disability criteria of Title XVI of the Social Security Act. The Agency’s action of denying petitioner’s application for SSI-Related Medicaid and Food Assistance was not upheld when it was found that the Department did not assist the Petitioner with the income verification. Therefore, the appeal was granted and remanded for the Department to complete the corrective action. Fla. Admin. Code, §65A-1.710-15F-08947, 15F-10518

Medicaid Processing

The petitioner’s appeal was dismissed when the Petitioner failed to meet the burden that there was a delay in processing any application for Medicaid Program benefits. The Respondent had previously taken action to approve Medicaid benefits with a share of cost effective November 2014, and there is no further action to be taken by the hearing officer. Fla. Admin. Code 65A-1.205- 14F-09910

Failure to Submit Requested Information

Acronym Key

ADC

Adult Day Care

ADL

Activities of Daily Living

ALF

Assisted Living Facility

BSCIP

Brain and Spinal Cord Injury Program

C.F.R.

Code of Federal Regulations

DME

Durable Medical Equipment

F.A.C

Florida Administrative Code

HHA

Home Health Aid

ICP

Independent Care Provider

PCA

Personal Care Assistance

PDN

Private Duty Nurse

POV

Power-operated vehicle

PPEC

Prescribed Pediatric Extended Care

QIT

Qualified Income Trust

SIPP

Statewide Impatient Psychiatric Program

SSA

Social Security Administration