Anderson v. Director, Dept. of Social Services
| Decision Date | 19 November 1980 |
| Docket Number | Docket No. 78-4731 |
| Citation | 101 Mich.App. 488,300 N.W.2d 921 |
| Parties | Arlene ANDERSON, Plaintiff-Appellant, v. DIRECTOR, DEPARTMENT OF SOCIAL SERVICES, Defendant-Appellee. 101 Mich.App. 488, 300 N.W.2d 921 |
| Court | Court of Appeal of Michigan — District of US |
Frank J. Kelley, Atty. Gen., Robert A. Derengoski, Sol. Gen., Erica Weiss, Asst. Atty. Gen., for defendant-appellee.
Before WALSH, P. J., and KELLY and OPPLIGER, * JJ.
AFTER REMAND
Plaintiff, the recipient of Aid to Families with Dependent Children, appeals the determination of the Kent County Circuit Court which affirmed the denial of certain dental benefits requested by her under Michigan's Medicaid [101 MICHAPP 490] plan, 42 U.S.C. § 1396 et seq., M.C.L. § 400.105 et seq.; M.S.A. § 16.490(15) et seq.
On April 7, 1977, plaintiff's dentist submitted an authorization form to defendant Department of Social Services for the following proposed dental services: (1) perio scaling and root plane, (2) prophylaxis (cleaning), (3) root canal, and (4) five fillings. Defendant denied the authorization request because the treatment was not a covered medicaid benefit for those over 21 years of age.
Plaintiff then sought an administrative hearing and included a partial plate as part of the requested medical assistance. The administrative law judge found that plaintiff was not entitled to benefits for a partial plate or a root canal on the ground that plaintiff's condition did not fit within the meaning of the emergency treatment under Item 512.B.1 of the Medical Assistance Eligibility Manual.
Plaintiff appealed to Kent Circuit Court, which affirmed the decision of the administrative law judge. The court noted that the administrative record was inadequate to determine whether dental benefits could have been provided under any other provision of Michigan's medicaid plan.
Plaintiff then appealed to the Court of Appeals which, on September 25, 1979, remanded the case to the circuit court for further evidence on whether or not the requested dental services were covered under the medicaid program and, if not, whether such limitation violated the Federal requirement that the scope of services be sufficient to reasonably achieve the purpose of providing dental services. See Appendix A.
At the hearing following remand on January 2, 1980, Dr. William J. Hanratty, Assistant Director [101 MICHAPP 491] of Dentistry for the Bureau of Health Services Review, Department of Social Services, was the sole witness. Dr. Hanratty testified that a root canal was not a covered benefit for adult medicaid recipients. Tooth extraction, a generally accepted alternative procedure, was a covered benefit. Dr. Hanratty also stated that the extraction of plaintiff's infected tooth would not cause any health or chewing problems. The cost differential between a root canal and extraction, $450 versus $18 respectively, was the main rationale for the disallowance of the former treatment. Dr. Hanratty testified that defendant's limited amount of resources could best be allocated to the greatest number of individuals and those in greatest need under the current medicaid guidelines.
Dr. Hanratty further testified that dentures are a covered benefit if they are necessary to correct masticatory deficiencies likely to impair general health. Dental Bulletin No. 14 states that the furnishing of a partial plate is a covered benefit for adult medicaid recipients only where an individual has either (1) fewer than six posterior teeth in occlusion (in bite), or (2) all four incisors (front teeth) in one arch missing.
Dr. Hanratty stated that these criteria (formulated by Dr. Levin, former director of the Dental Division of the Department of Social Services and the Michigan Dental Association), specified when a person's biting or chewing ability was significantly impaired. Since plaintiff has only one upper back tooth missing, she did not qualify for a partial plate. Dr. Hanratty also stated that the absence of that one tooth would not cause any health or chewing difficulties.
A prior approval request form submitted by a dentist is also a prerequisite to medicaid coverage [101 MICHAPP 492] for a partial plate. Dr. Hanratty stated that this prior authorization requirement assisted in controlling costs and assuring that a dentist followed generally accepted dental practices.
After the hearing, the trial court again affirmed the decision of the administrative law judge and stated that the provisions of the Michigan medicaid plan with respect to dental services are reasonable and do not violate Federal law.
Plaintiff initially challenges the denial of medicaid benefits on the grounds that defendant must provide all dental services, defined by regulation as "diagnostic, preventive, or corrective procedures provided by * * * a dentist * * * ". 42 CFR 440.100. Plaintiff contends that since a root canal and a partial plate fit within the definition of dental services, they must be provided under 42 CFR 400.2(b), which reads as follows:
This argument is unpersuasive. The wording of the regulation itself does not support plaintiff's interpretation. 42 CFR 440.2(b) merely states that Federal matching funds are available for services defined in the regulations. There is no requirement that the defined services must be provided by the state. Furthermore, in Beal v. Doe, 432 U.S. 438, 97 S.Ct. 2366, 53 L.Ed.2d 464 (1977), the Supreme Court ruled that all services within the five mandatory categories under medicaid need not be covered. States are not required to offer a more expansive group of benefits for optional medical services such as dental care. An argument similar [101 MICHAPP 493] to plaintiff's was rejected by the Court in Dist. of Columbia Podiatry Society v. Dist. of Columbia, 407 F.Supp. 1259, 1263-1264 (D.D.C.1975), which stated:
to furnish medical assistance and services. States can choose whether to participate at all; a participating state can choose to include in its plan only the "categorically needy," or it can also include the "medically needy"; a participating state is free to choose which, if any, of the optional services it will include in its Plan. Such options, amongst others in the statute, are designed to afford each state the opportunity to design a Medicaid Plan tailored to the needs and conditions in that state.
Plaintiff's second argument merits more extensive discussion. Under 42 CFR 440.230, Michigan's dental plan must meet a "sufficiency of amount, duration and scope" test. The regulation provides that:
Plaintiff argues that Michigan's medicaid plan is violative of this test because the denial of the requested benefits was arbitrary, was not based on medical necessity, and was not in the best interests of the medicaid recipients. We disagree.
Our review of the medicaid standards adopted by defendant regarding the extent of assistance is very limited. As stated in Budnicki v. Beal, 450 F.Supp. 546, 557 (E.D.Pa., 1978):
Since a state plan must be reasonable in light of the purpose of the Federal statute, we look to that statute, Title XIX, in defining the purpose for which it was enacted. The Federal medicaid statute provides that:
"(f)or the purpose of enabling each State, as far as practicable under the conditions in such State, to furnish (1) medical assistance on behalf of families with dependent children * * * and (2) rehabilitation and other services to help such families and individuals attain or retain capability for independence or self-care, there is hereby authorized to be appropriated for each fiscal year a sum sufficient to carry out the purposes of this subchapter." 42 U.S.C. § 1396. (Emphasis supplied.)
Another provision of the statute also states that the state plan must:
[101 MICHAPP 495] "provide such safeguards as may be necessary to assure that eligibility for care and services under the plan will be determined, and such care and services will be provided in a manner consistent with simplicity of administration and the best interests of the recipients." 42 U.S.C. § 1396a(a)(19).
Therefore, as noted in White v. Beal, 555 F.2d 1146, 1151 (C.A. 3 1977)...
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