State of north carolina in the office of administrative hearings



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STATE OF NORTH CAROLINA IN THE OFFICE OF

ADMINISTRATIVE HEARINGS

COUNTY OF CUMBERLAND 07 DHR 0798

Lynette Poston )

)

Petitioner, )



)

v. ) ) DECISION

NC Department of Health and Human Services, )

Division of Medical Assistance )

)

Respondent. )


A Petition for a contested case hearing was filed in the North Carolina Office of Administrative Hearings on May 16, 2007. The Petitioner contested Respondent’s decision to deny Petitioner’s request for various dental services.


This matter was heard before the undersigned in Fayetteville, North Carolina, on April 9, 2008.
Petitioner appeared pro se. Respondent was represented by Joel L. Johnson, Associate Attorney General, North Carolina Department of Justice.
ISSUE
Whether Respondent exceeded its authority or jurisdiction, acted erroneously, failed to use proper procedure, acted arbitrarily or capriciously, or failed to act as required by law or rule, and otherwise substantially prejudiced Petitioner’s rights by denying the requested dental services.
FINDINGS OF FACT
1. On January 23, 2007, Petitioner’s dentist, Dr. Zubick, submitted a prior approval request to the Division of Medical Assistance (DMA) requesting Current Dental Terminology (CDT) codes D2750 (crown-porcelain fused to high noble metal), D2952 (cast post and core in addition to crown), D6750 (crown-porcelain fused to high noble metal), and D6250 (pontic-resin with high noble metal). None of the requested services are listed in the Dental Manual.
2. DMA denied the requested dental services based on lack of medical necessity in addition to the fact that only the procedure codes listed in the North Carolina Dental Manual are covered under the NC Medicaid Dental Program.
3. Petitioner appealed the denial to the Department of Health and Human Services (DHHS) Hearing Office. The Hearing Officer upheld the denial based on lack of medical necessity as well as the Dental Policy which does not cover the requested services.
4. Petitioner argued that porcelain crowns are medically necessary because no other alternative dental service would withstand the future radiation treatment which is anticipated by Petitioner.
5. At the time of the Respondent’s review, the radiographs provided by Petitioner’s dentist, were between one and two years old and did not show the necessity for any crowns on teeth numbered 4 – 7 (top front teeth).
6. Information was received from Dr. Zubrick concerning the effects of radiation on the dental issues of Petitioner, but was not specific to issues raised by Respondent. Despite requests for further specific information by Dr. Mark Casey, Dental Director for Respondent, no further information from the treating physicians on the specifics of the radiation treatment and how it affected Petitioner, in particular concerning dental issues, was received by Respondent.

7. According to Dr. Casey, there is no evidence that porcelain crowns would be favorable over resin crowns, or even tooth-colored fillings, even considering the possibility of future radiation therapy. According to Dr. Casey, resin crowns could possibly have advantages over porcelain crowns based on Petitioner’s circumstances. Neither porcelain nor resin crowns are covered dentals service for adults.


8. Brenda Brantley is a Dental Policy Analyst for Respondent, and she confirmed that the requested services are not available under the NC Medicaid Dental Program and, further, that the Petitioner’s requests and circumstances do not fit within any existing exception that would allow Medicaid to pay for porcelain crowns for Petitioner. Ms. Brantley acknowledges that her sworn affidavit states that resin crowns are an acceptable and available treatment option for the Petitioner and that it remains an option that is open to the Petitioner.
9. Petitioner offered into evidence a letter written by her dentist in which Dr. Zubick suggested that porcelain crowns would withstand radiation therapy better than other dental services. Dr. Zubick was not present to testify nor did his written statement offer documentation of his claim that porcelain crowns would be necessary over alternative services.
10. Only those services which are medically necessary may be paid under the Medicaid program. 10A NCAC 22O .0301.
11. Only those procedures listed in the North Carolina Dental Manual are generally covered under the North Carolina Dental Program. 10A NCAC 22O .0204. Based on Ms. Brantley’s sworn affidavit and the testimony of Dr. Casey, resin crowns and porcelain crowns are covered services listed in the North Carolina Dental Program which could be made available to Petitioner as an exception if she otherwise met the tests to qualify for an exception.

12. Exceptions to the requirements may be made when recommended by the Dental Consultant and approved by the agency head when: (1) an emergency condition causing pain or suffering needs immediate attention; or (2) an alternative dental treatment plan is safe, medically acceptable and less expensive but is not on the procedure list; or (3) the procedure is medically necessary and is of such complexity and the circumstances are so unusual that a coverage decision requires individual consideration based on the medical condition of the client, diagnosis, prognosis, and the unavailability of other alternative treatment options. 10A NCAC 22O .0204.


Based upon the foregoing facts, this Court makes the following:
CONCLUSIONS OF LAW
1. The North Carolina Office of Administrative Hearings has jurisdiction over the parties and subject matter of this contested case pursuant to N.C. Gen. Stat. §150B-23 et seq. All necessary parties have been joined. The parties received proper notice of the hearing in this matter.
2. Petitioner had the burden of proving by preponderance of the evidence that Respondent exceeded its authority or jurisdiction, acted erroneously, failed to use proper procedure, acted arbitrarily or capriciously, or failed to act as required by law or rule, and otherwise substantially prejudiced Petitioner’s rights by denying the requested dental services.
3. Petitioner’s requested dental services are not covered under the NC Medicaid Dental Program.
4. Exceptions to the general requirements may be made under certain circumstances listed in 10A NCAC 22O .0204. Petitioner does not fall within those exceptions. Petitioner has failed to prove “medical necessity” for the services she has requested.
5. Petitioner has not presented sufficient evidence to conclude that Respondent exceeded its authority or jurisdiction, acted erroneously, failed to use proper procedure, acted arbitrarily or capriciously, or failed to act as required by law or rule, and otherwise substantially prejudiced Petitioner’s rights by denying the requested dental services.
DECISION
NOW, THEREFORE, based on the foregoing Findings of Fact and Conclusions of Law, the Undersigned AFFIRMS Respondent’s decision to deny the requested dental services.
ORDER AND NOTICE
The North Carolina Department of Health and Human Services, Division of Medical Assistance, will make the Final Decision in this contested case. N.C. Gen. Stat. § 150B-36(b), (b1), (b2), and (b3) enumerate the standard of review and procedures the agency must follow in making its Final Decision, and adopting and/or not adopting the Findings of Fact and Decision of the Administrative Law Judge.
Pursuant to N.C. Gen. Stat. § 150B-36(a), before the agency makes a Final Decision in this case, it is required to give each party an opportunity to file exceptions to this decision, and to present written arguments to those in the agency who will make the Final Decision. N.C. Gen. Stat. 150B-36(b)(3) requires the agency to serve a copy of its Final Decision on each party, and furnish a copy of its Final Decision to each party’s attorney of record and to the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6714.
This the 21st day of April, 2008.

_______________________________

Donald W. Overby

Administrative Law Judge





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