Medicaid Appeals Enable Family to Continue Providing for Loved Ones

Dennis and Valerie’s Story

Valerie Scholes, 29, and her brother, Dennis (Den), 31, live in rural ranch country, together with their parents and several more siblings. Their entire family participates in their physical and emotional care and Valerie and Dennis always have company, spending their days in their bright, cozy living room engaging with their family. At night, their mother, Carol, sleeps in a recliner next to Valerie and Den’s father shares a room with him. Their three siblings also pitch in, delighting in the way Den teases and shares his passion for cars and supporting Valerie’s love for babies, jewelry, and “anything with four-legs.”

In the past, Valerie and Den’s disability caused them to aspirate when eating. As a result, ten-years ago, Valerie began using a feeding tube and four-years later, Den did also. Medicaid covered the cost of their liquid diet, their only source of nutrition—at least until this year. When Den’s annual reauthorization of services came around this year, Medicaid declined to pay for the food, stating there was no medical need for it and suggested the family purchase the food with Food Stamps. When Valerie’s review came around a few months later, Medicaid issued the same decision. The cost of just one-month’s food for the two siblings is $700 and Medicaid’s decision hit the Scholes family hard. Fearful for Valerie and Den’s health, they reached out to the DLC for help.

“Nate [Crippes] was awesome,” said Carol of the DLC attorney that helped them. “Medicaid gave us the run-around and [Nate] waded through 300-pages of medical records to find the three that would help us with our case. He went above and beyond, even accompanying us to an appointment with the nutritionist to gather information to prove the liquid food is specialized and serves a medical purpose.”

Nate represented the Scholes through the Medicaid appeal process, and as a result of his efforts, Medicaid reversed their decision and began to pay for Valerie and Den’s food again. Several months later, the Scholes are still thrilled with the result and grateful that their full focus could shift back to giving Valerie and Den a meaningful life.