Medicaid denies treatment request for young man with brain injuries PDF Print E-mail
Friday, 01 August 2014 10:30

By ROBERT PIERCE

• Leader & Times

 

On March 29, 2010, Anthony Martinez sustained a traumatic brain injury from being struck on the left side of his head with a rock and a 2 by 4 piece of wood in a physical assault in Liberal.

Martinez, 25, was transferred to Wesley Medical Center, where he was incubated. A CT scan revealed TBI, and Martinez was immediately transferred to the operating room for a craniotomy, which left him in a coma for three weeks post injury.

Martinez has undergone multiple neurosurgeries along the occipital plate since for hematoma management by the neurosurgeon. He is also prone to seizures since the injury.

Martinez likewise has a history of marijuana and alcohol abuse prior to the TBI, according to Dr. Ron Broughton, chief clinical officer for Brookhaven Hospital in Tulsa, Okla., one of the places Martinez was referred to since the injury.

“In spite of multiple consultations from medical care providers, Anthony has been consistently non-compliant to his medical treatment plan,” Broughton said in a projected rehabilitation treatment plan.

The doctor added on Feb. 10, while incarcerated for his behaviors, Martinez experienced a tonic-clonic seizure associated with a loss of consciousness and was again transported to Wesley for treatment.

Broughton said Martinez’s mother, April Southard, who is the primary caregiver, is no longer able to manage her son’s behaviors and is seeking more intensive treatment related to his cognitive and behavioral deficits.

Southard said Brookhaven and Wesley are not the only medical officials she has approached about her son’s situation.

“I have contacted a lot of people,” she said. “They know about the situation.”

Martinez was referred to Brookhaven by an area medical facility, Meade Rural Health Clinic, and Dr. Seeley T. Feldmeyer of the clinic said Martinez would benefit to his advantage to being admitted into the long-term rehab.

“He was recently seen in our clinic with his mother, who is very concerned with his behavior,” Feldmeyer said in a referral letter. “He has been persuaded by his peers to partake and abuse marijuana and methamphetamines. To seek their approval, he uses and has become addicted to these substances.”

The Meade doctor added Southard reported that Martinez’s behavior has been uncontrollable.

“At times, he has tantrums and starts throwing and hitting,” Feldmeyer said. “He also suffers from seizures since the TBI and is currently being medicated with Depakote 500.”

This is one of a few medications Martinez is taking, but Feldmeyer said Martinez has not been compliant in taking his medicines due to some undesirable side effects.

Recently, Southard requested coverage for her son’s rehabilitation from Martinez’s primary Medicaid provider, Sunflower State Health Plan, who informed Southard that the request was denied.

Southard said Martinez has another provider in United Health, but education is taking place through that provider, which she called a “long process.”

In the denial letter, Sunflower’s medical director, Dr. Lisa Nordberg, said the request had been reviewed and denied because it was deemed “not medically necessary” because more than one therapy is not required.

“There is no new illness, injury or surgery in the last 30 days, and there is no new impairment,” she said.

This, as well as other issues with the case, left Southard somewhat confused.

“Medicaid told me ‘Why doesn’t law enforcement do something about it?’” she said. “It’s a medical condition. Why does law enforcement have to take care of the situation when it is a medical condition? There is no facility in Kansas to handle the cognitive, neurological part of it, but they said they will not send anybody out of the state of Kansas.”

Southard said Brookhaven is a Kansas Medicaid provider, but she said medical officials continue to do nothing about her son’s case.

“They will not send him there,” she said. “This is an issue with the other people.”

And because Martinez cannot be sent out of state, there is very little, if anything, that can be done at this time.

“There’s nothing in Kansas that can help him,” Southard said.

The mother said she knows Sunflower is paid by the state of Kansas to save money. This, she said, is why the evaluations on her son were done, but she is still confused as to why law enforcement should have to take care of the situation.

Southard is currently in contact with the state’s Disability Rights Center and has an attorney looking to file an appeal. With her son requiring around-the-clock supervision, she has also lost her job.

Southard said finding help is an urgent need for the case.

“He has suicidal tendencies,” she said. “All they thought he needed was outpatient occupational therapy.”

Southard said Brookhaven is willing to take care of Martinez’s problems, and Broughton confirmed that willingness.

“The estimated length of stay is six months to one year at this time,” the Tulsa doctor said in his treatment plan. “Brookhaven Hospital’s director of utilization review works with the State of Kansas Medicaid worker, Brookhaven Hospital’s social worker, guardian and other team members as indicated to secure an appropriate placement back in Kansas.”

Southard said the lack of medical care for her son is a big issue, and she is not the only one experiencing the problem. She added many medical people are just now starting to learn how TBI works and how to treat the condition.

“I’ve been talking to Amy with the Kansas Traumatic Brain Association,” she said. “They are trying to educate these people. They have no education on traumatic brain injury on how they work.”

Southard said she is looking at other avenues for help with the case.

“I have been talking to a girl named Erica at the Kansas Governor’s Office,” she said. “She has been trying to help me on this situation too.”

 

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The High Plains Daily Leader and Southwest Daily Times are published Sunday through Friday and reaches homes throughout the Liberal, Kansas retail trade zone. The Leader & Times is the official newspaper of Seward County, USD No. 480, USD No. 483 and the cities of Liberal and Kismet.  The Leader & Times is a member of the Liberal Chamber of Commerce, the Kansas Press Association, the National Newspaper Association and the Associated Press.

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