Brooks v. Smith

• Citation: 356 A.2d 723
• Parties: Marjorie BROOKS v. David E. SMITH, Commissioner of the Department of Health and Welfare.
• Decision Date: 30 April 1976
• Court: Maine Supreme Court

Page 723

356 A.2d 723

Marjorie BROOKS v. David E. SMITH, Commissioner of the Department of Health and Welfare.

Supreme Judicial Court of Maine.

April 30, 1976.

Pine Tree Legal Assistance, Inc. by Susan Calkins, Portland, for plaintiff.

Chalmers Hardenbergh, Staff Atty., Dept. of Health and Welfare, Augusta, for defendant.

Before DUFRESNE, C. J., and WEATHERBEE, POMEROY, WERNICK and ARCHIBALD, JJ.

WEATHERBEE, Justice.

The plaintiff, Mrs. Brooks, is a recipient of Aid to Families With Dependent Children and it is agreed that both she and her daughter, age 13, are within the class of persons eligible for medical assistance under the Medicaid program and that the child is thus eligible for some dental treatment. The plaintiff requested that the Department of Health and Welfare (now the Department of Human Services) approve orthodontia for the child. The former Commissioner ruled that the dental services available under this program do not include orthodontia. The plaintiff sought a review of his decision under M.R.C.P., Rule 80B. ¹ A Justice in the Superior Court held that the child is in need of orthodontia and that the Commissioner's interpretation of the controlling statutes and regulations was erroneous. He ordered the Commissioner to find the child eligible for such treatment.

The present Commissioner appealed from this judgment. We deny the appeal.

The Medicaid program came into existence in 1965 as an amendment to the Social Security Act to provide federal financial assistance to states for medical assistance to those 'whose income and resources are insufficient to meet the costs of necessary medical services'. 42 U.S.C. §§ 1396-1396d. It is administered in Maine by the Department of Human Services and is paid for with both state and federal dollars.

The Federal statutes (to be discussed in more detail later) require the participating states to provide, as a minimum, certain described medical services to their eligible citizens, and regulations promulgated by the Department of Health, Education and Welfare implement these mandates by a more detailed schedule of medical (including dental) services which the states are obligated to furnish. The Medical Assistance Manual (MAM) and Code of Federal Regulations (C.F.R.).

Upon enterning into participation in this federal-state program, this State promulgated regulations to guide its own Medicaid program. They were published as the Maine Medical Assistance Manual (MMAM). In the respects which concern us, at least, they duplicate the federal regulations with some minor variations which we will discuss later.

No statutory provision or federal or state regulation either specifically approves or specifically forbids orthodontic treatment as such.

Now, against this brief statutory-regulatory background, we will examine the procedure followed in this case.

The plaintiff had requested the Commissioner to pay for future orthodontic treatment for the child which had been commenced but was due to be discontinued because of the mother's inability to pay for it. She supported her request by letters from dentists describing the child's oral deformity and need of dental treatment, together with her x-rays. This material was reviewed by the Director of the Bureau of Medical Care and by the Department's Dental Consultant. The Medical Claims Consultant of the Division of Medical Assistance then wrote the plaintiff's legal advisor:

'Your request for approval for orthodontic work for (the child) has been carefully reviewed by Dr. Gilbert Marcotte Director of the Bureau of Medical Care and Dr. Alonzo Garcelon, Dental Consultant to the Department of Health & Welfare.

The need of orthontia for (the child) has been substantiated. However, as the Medicaid Dental Program does not cover orthodontia, it is necessary to not approve this case.

We hope that future funding will enable us to cover orthodontics, as there is a great need here. However, it was necessary to establish priorities of care with the limited money we were allotted and restoration and replacement were established at the top of the list.'

Following the disapproval of her request by the Medical Claims Consultant, the plaintiff sought a 'fair hearing'. Such a hearing was held before the Department Hearing Officer. Both the plaintiff and the Department were represented by persons who were not attorneys. The plaintiff testified and introduced letters from her medical experts, the letter from the Medical Claims Consultant, a model of the child's teeth and her x-rays. It was not contradicted that the child has a severe dento-facial deformity with impaction of second bicuspid teeth and a protrusion which makes it impossible for her to eat some foods and prevents complete closing of the lips due to lack of space in the dental arches. This deformity is more than a cosmetic problem and is severe enough to constitute a hazard to the child's future dental health. Earlier extractions had left spaces which, if unclosed by orthodontia, increased her chances of temporo-mandibular joint problems and periodontal disease. An examination of the x-rays can leave no doubt as to the severity of her present condition. It was the opinion of her dentist that discontinuation of the orthodontic procedure could be very detrimental to her oral health.

The record of this hearing formed the factual basis for the Commissioner's ruling. He held that:

'At issue was whether Medical Services Specialist erred in denying approval of payment for dental care. Applicant is in need of orthodontia. She submitted testimony, together with exhibits, to indicate the need. Refusal was based on the fact that this type of care is not covered by the rules and regulations. Applicant submitted copies of Federal regulations. The Department submitted copies of State regulations. Careful review of the pertinent rules fail to reveal error.' (Emphasis added.)

The Justice in the Superior Court reviewed the matter on the record and granted the motion for judgment for the plaintiff. He found that:

'1. The Finding of Fact made by the defendant in his administrative decision dated July 29, 1974, is correct. The defendant found that the plaintiff's child is in need of orthodontia. The factual finding of the defendant was made following an administrative hearing at which the plaintiff produced testimony and documents to substantiate the need (for) the orthodontia. The factual finding of the defendant was based upon substantial and credible evidence given at the administrative hearing.

2. The Conclusion of Law reached by the defendant in the hearing decision dated July 29, 1974, that the plaintiff's child was not entitled to orthodontia treatment because such treatment is not covered by rules and regulations is erroneous. The plaintiff's child is entitled to orthodontic treatment pursuant to 42 U.S.C. S.C. §§ 1396a(a)(13)(B) and 1396d(a)(4)(B); 45 C.F.R. § 249.10(a) (3)(iv); and the Maine Medical Assistance Manual.'

The Child's Need For Orthodontia

The Commissioner, after reviewing the 'fair hearing' record, found that

'Applicant is in need of orthodontia.'

Now, on appeal, defendant urges us that this statement should not be construed as a finding that the child's dental condition is of such a serious nature as to meet federal standards for entitlement to treatment (even if orthodontia is an available treatment-an issue to be discussed later).

At this point it will be sufficient to say that the federal regulations commit the Medicaid program to 'restoration of teeth and maintenance of dental health' (45 C.F.R. § 249.10(a)(3)(iv)), to 'correct or ameliorate . . . abnormalities' (MAM 5-70-20(A)(3)) and to treat dental problems which, if untreated, 'may become acute dental problems or may cause irreversible damage to the teeth or supporting structures.' MAM, 5-70-20(G)(1).

The Commissioner was aware that both Dr. Marcotte and Dr. Garcelon had approved of the application for the child's orthodontia and that the Medical Claims Consultant (whom he apparently referred to as the 'Medical Services Specialist') had found that her need had been substantiated. He had before him the record of the fair hearing with the reports from the child's dental experts and the undisputed evidence of her serious dental defects and he had read there her attorney's insistence that the question of her medical eligibility was an issue which should be fully presented at that hearing. No evidence disputing this need was presented.

It is inconceivable that the Commissioner intended his finding of her 'need of orthodontia' to mean anything less than that her problem threatens her dental health. If he had not meant that she was medically eligible, there would have been no need for him to have gone further with the other issue.

Does the Scheme of Federal Statutes, Federal Regulations and State Regulations Require the Commissioner to Provide Orthodontia to the Plaintiff's Child?

The letter of denial from the Medical Claims Consultant does not specify the precise authority for the Department's refusal. The Consultant explained that 'as the Medicaid Dental Program does not cover orthodontia it is necessary to not approve this case.' We take it that the Department's position was not that the federal statutes and regulations forbid the State's furnishing orthodontic treatment but, instead, that they do not require it and that the State Department was free to adopt regulations excluding such treatment in order to utilize more advantageously the limited funds available to it.

We understand the Commissioner's decision to have so interpreted the Consultant's denial, that he adopted this position and that he interprets the 'rules and regulations' of his Department as excluding this type of treatment.

That this is the defendant's position is made quite clear by the defendant's answer to plaintiff's 80B complaint which answer asserts in part:

'(T)he treatment was denied on only one ground: due to the...