Dear Bob,

The democrats claim to be the party that 'cares more'. That has not been my
experience.

My wife and I are the proud parents of a brain-injured child. Jimmy is now
6 years old and his mobility, balance, and speech have been impaired by a
mid-brain injury--he's not sitting up or walking yet.

18 months ago we learned of a treatment that reverses brain-injury called
Hyperbaric Oxygen Therapy (HBOT). SPECT-scan imaging verifies the reversal
of the brain-injury. SPECT-scans use tissue metabolism to "draw a picture"
of scanned tissue. If there's no tissue function (metabolism), then the
tissue doesn't appear. After HBOT, the tissue appears--which means the
tissue is now functioning.

Jimmy is a Georgia Medicaid recipient, and we asked for reimbursement for
more HBOT. We have been denied four times for four different reasons. The
state has never denied the efficacy of the treatment.

Most brain-injured children are Medicaid recipients, and according to Title
XIX of the Social Security Act, as described in 42 U.S.C. §1396(a)(43),
Medicaid-participating states must provide to eligible minors under the age
of 21 certain mandatory medical services--including Early and Periodic
Screening, Diagnostic, and Treatment Services [EPSDT].

Ten years ago Paragraph 5 was added specifically added so that
brain-injured children could get oxygen. It reads "(5) Such other necessary
health care, diagnostic services, treatment, and other measures to correct
or ameliorate defects and physical and mental illnesses and conditions
discovered by the screening services, whether or not such services are
covered under the State plan."

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

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

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

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

The SPECT-scan and clinical evidence--statements from Jimmy's pediatrician
are proof that HBOT is necessary to correct or ameliorate Jimmy's defects
and physical or mental illness.

I called the democratic governor of Georgia, Roy Barnes, and asked for help
and got just the opposite. Our case was taken out of the legal department
of Medicaid and given to the state attorney general. The state attorney
general in turn hired a private attorney at a cost of $300 an hour to keep
our child away from a $150/hour, proven treatment that has a legal right to
under federal law.

If that's not a rat, I don't know what is.