With respect to the 2 hours of home healthcare, IMR's Rationale was: "California Medical Treatment Utilization Schedule (MTUS) states home healthcare is selectively recommended on a short-term basis following hospitalization and major surgical procedures. It is also selectively recommended to prevent (re)hospitalization, to overcome deficits in activities of daily living (ADLs), and/or to provide nursing, therapy and/or supportive care services for those who would otherwise require inpatient care. In this case, the injured worker has a history of a spinal cord injury. The injured worker utilizes a wheelchair; however, there is a lack of evidence that he is unable to perform medical care to warrant home health aide. As such, the request for home health aide services 2 hours a day, 7 days a week for 3 months is not medically necessary."

What did the above paragraph say about overcoming deficits in activities of daily living? In Dr. Sangnil's report dated 04/25/2022, first page, under subjective, "Patient reports he lives alone at home but his mother does have to help him with groceries and chores due to his paraplegia. "

OK, I guess we have to blame the doctor for not saying, "the patient cannot go to the grocery store because the insurance carrier has denied all transportation for activities of daily living and for all medical treatment. So he needs help grocery shopping because he cannot reach the low fat milk and reach into the freezer section to get frozen food." The doctor should also say, "the patient in his wheelchair and cannot sweep the floors and reach down to use a dust pan", "the patient cannot put away dishes because he is unable to stand and reach the cabinets that were never modified", or "the patient cannot reach the corners of the walls to dust away cobwebs and certainly cannot clean the bathtub." I can see the treating doctors around the State of California doing this, can't you!! Don't answer that question, it was rhetorical.

Likewise, MAXIMUS upheld the non cert for a gardener and pool cleaner. The reason as you can see is quoted exactly: Gardening and pool maintenance, 3 months is not medically necessary and appropriate. UR Evidence Cited: The guidelines used by the Claims Administrator are not clearly stated in the UR determination. IMR Evidence Cited:

MTUS Initial Approaches to Treatment 2022 Guidelines, Section(s): Treatment Recommendations: Home Health Care Services. IMR Rationale: California Medical Treatment Utilization Schedule (MTUS) states home healthcare is selectively recommended on a short-term basis following hospitalization and major surgical procedures. It is also selectively recommended to prevent (re)hospitalization, to overcome deficits in activities of daily living (ADLs), and/or to provide nursing, therapy and/or supportive care services for those who would otherwise require inpatient care. In this case, the injured worker has a history of a spinal cord injury. The injured worker utilizes a wheelchair; however, the request is not for medical care and there is no associated frequency.

Did you see it ? Those words, "to overcome deficits in activities of daily living." Well, but for his spinal cord injury, this 25 year old confined for life can not maintain his pool for pool therapy and now has to pay for it himself. Wouldn't this help to overcome his deficits in his ability to clean his pool? Point well stated MAXIMUS, the treating physician should have written that pool maintenance must be done once a week and hence payment made on a monthly basis until the patient can either walk or does not have a pool.

The problem is that the treating doctors are actually treating patients while the UR physicians and MAXIMUS' anonymous reviewing physicians are reading records. So the frequency of the service requested is the issue, really.

With respect to the gardening, the treating doctor should have written, due to the patients paraplegia he cannot push a lawnmower, or pull weeds from the ground. Carrying bags of trash to and from the house or yard will require assistance at least one time per week. So who suffers here? You guessed it, the 25 year old who fell due to the employer's negligence. Ericsson you should be so proud of your work comp carrier, Chubb administered by Constitution State Services and the insurance you paid for to take care of your employees.

Now for the final request, a modified vehicle. There is no way, is there, that MAXIMUS could deny the specific request as outlined by the Driving Evaluator as to what the patient would need to drive and find some self-worth and respect. Of course there is, and they did. MAXIMUS Non cert based on the following: "California Medical Treatment Utilization Schedule (MTUS) does not address the request. Official Disability Guidelines state is recommended generally if there is a medical need and if the device or system meets Medicare's definition of durable medical equipment (DME). In this case, the injured worker has a history of a spinal cord injury. The injured worker utilizes a wheelchair; however, there is a lack of documentation of evaluation demonstrating ability to drive with modifications. As such, the request for modified vehicle that includes left colunm mounted push/pull hand control, a left drop-down signal extension and a right spinner knob at 2 o'clock is not medically necessary.

I guess the old saying, "you can lead a horse to water but you can't make him drink!", holds true to MAXIMUS and UR physicians. See not only did we provide the drivers evaluation to the UR physician, we made sure to send it to MAXIMUS with a letter outlining the evaluation and the request. But obviously MAXIMUS didn't read it. So now what? Another several months of Appeals and this 25 year old who lives by himself has to rely on his mom and dad to help with the cooking, cleaning, driving, gardening and pool maintenance while the Chubb insurance company continues to collect premiums for services that are medically necessary to cure or relieve from the effects of the industrial injury.