Callen v. Rogers

• Decision Date: 18 October 2007
• Docket Number: No. 1 CA-CV 05-0792.,1 CA-CV 05-0792.
• Citation: 216 Ariz. 499,168 P.3d 907
• Parties: Linda CALLEN, Plaintiff/Appellant, v. Anthony ROGERS, Director, Arizona Health Care Cost Containment System, in his official capacity; Arizona Health Care Cost Containment System, a state agency; and Health Choice Arizona, Defendants-Appellees.
• Court: Arizona Court of Appeals

168 P.3d 907

216 Ariz. 499

Linda CALLEN, Plaintiff/Appellant, v. Anthony ROGERS, Director, Arizona Health Care Cost Containment System, in his official capacity; Arizona Health Care Cost Containment System, a state agency; and Health Choice Arizona, Defendants-Appellees.

No. 1 CA-CV 05-0792.

Court of Appeals of Arizona, Division 1, Department D.

October 18, 2007.

Community Legal Services By Srinivasan Varadarajan, Phoenix, Attorneys for Plaintiff/Appellant.

Johnston Law Office PLC By Logan T. Johnston, III, Phoenix, Attorneys for Defendants/Appellees Rogers and Arizona Health Care Cost Containment System.

Campbell Yost Clare & Norell PC By John J. Checkett, James A. Frisbie, Phoenix, Attorneys for Defendant/Appellee Health Choice Arizona.

OPINION

SNOW, Judge.

¶ 1 Linda Callen appeals from the superior court's judgment affirming the Arizona Health Care Cost Containment System's ("AHCCCS") denial of a procedure Callen requested for the extraction of all of her remaining teeth. Because the Director of AHCCCS made no erroneous legal conclusions and his decision is supported by substantial evidence, we affirm.

FACTUAL AND PROCEDURAL BACKGROUND

¶ 2 Callen was enrolled as a member in Health Choice Arizona, a health plan that contracts with the state AHCCCS Administration to provide AHCCCS benefits to the eligible Arizona population. Callen was fifty-three years old at the time of the events giving rise to this appeal. She feared dentists and had not been to see one in more than thirty-two years. She apparently first sought treatment for a swollen and painful jaw at a hospital emergency room in August 2003. She was told that her teeth might be the cause of her pain. She was given antibiotics and pain medication and sent home.

¶ 3 She eventually obtained a referral from Health Choice to see a dentist, Dr. Susan Larsen. Callen consulted Dr. Larsen approximately eight months after Callen's emergency room visit. Dr. Larsen noted "severe periodontal disease, numerous missing teeth, gross calculus, caries, and extensive mobility." Dr. Larsen referred Callen to an oral surgeon, Dr. Jeffrey Kootman. Dr. Kootman requested authorization from Health Choice for extraction of all of Callen's remaining teeth and an alveoloplasty, a preparatory procedure for dentures. He proposed that the extractions and the alveoloplasty, in which tooth sockets are shaped, be performed at the same time under general anesthesia.

¶ 4 The state AHCCCS plan only provides coverage for "emergency dental care and extractions" for its adult members. Arizona Revised Statutes ("A.R.S.") section 36-2907(A)(5) (2003).¹ For purposes of implementing the statute, the Arizona Administrative Code ("A.A.C.") further defines "emergency dental care services" as:

(1) Oral diagnostic examination including laboratory and radiographs if necessary to determine an emergency medical condition;

(2) Immediate and palliative procedures, including extractions if medically necessary, for relief of severe pain associated with an oral or maxillofacial condition;

(3) Initial treatment for acute infection;

(4) Immediate and palliative procedures for acute craniomandibular problems and for traumatic injuries to teeth, bone, or soft tissue;

(5) Preoperative procedures; and (6) Anesthesia appropriate for optimal patient management.

A.A.C. R9-22-207(B).

¶ 5 Upon its review, Health Choice eventually approved the extraction of eight of Callen's teeth based on x-rays showing shaded areas appearing on the root tip of those teeth, which demonstrated abscesses. It determined that removal of these teeth qualified as "emergency dental care" because the extractions were medically necessary and required for relief of Callen's severe pain. Health Choice denied approval for the extraction of Callen's remaining ten teeth on which there was no shading. It also denied approval of the alveoloplasty and the general anesthesia for the extractions. Callen requested an administrative hearing to review Health Choice's decision.

¶ 6 At the hearing, Callen testified that her "teeth hurt every day, although she could not discern which teeth hurt." The Administrative Law Judge ("ALJ") heard Callen's testimony and reviewed the documents pertinent to Callen's request submitted by both sides. The ALJ found that the procedures requested constituted emergency dental care.

¶ 7 While adopting many of the ALJ's factual findings, the AHCCCS Director determined that Callen had not introduced sufficient evidence to establish that the extraction of her teeth that did not show abscesses constituted emergency dental care. He also found no documentation supporting Callen's need for dentures and thus no need for an alveoloplasty. He also did not find a need for Callen's teeth to be removed under general anesthesia.

¶ 8 Callen appealed to the superior court. The superior court affirmed the Director's decision and Callen timely appeals. We have jurisdiction pursuant to A.R.S. § 12-2101(B) (2003).

ANALYSIS

¶ 9 On appeal from the superior court's review of an administrative decision, we consider whether the agency action was supported by the law and substantial evidence and whether it was arbitrary, capricious or an abuse of discretion. See J.L.F. v. Ariz. Health Care Cost Containment Sys., 208 Ariz. 159, 161, ¶ 10, 91 P.3d 1002, 1004 (App.2004).² In reviewing questions of law decided by the administrative agency, we reach our own legal conclusions. See Smith v. Ariz. Long Term Care Sys., 207 Ariz. 217, 221, ¶ 19, 84 P.3d 482, 486 (App.2004). However, in reviewing factual determinations, we decide "only whether there is substantial evidence to support the administrative decision. A decision supported by substantial evidence may not be set aside as being arbitrary and capricious." Id. at 220, ¶ 14, 84 P.3d at 485 (citations omitted).

¶ 10 Callen makes three arguments on appeal. She argues first that, pursuant to Medicaid, once Arizona provides any dental coverage as an AHCCCS benefit, it is obliged to provide all necessary dental care to its AHCCCS-eligible population. Second, Callen argues that despite the statute specifying that AHCCCS covers only "emergency dental care," a companion provision covering outpatient services is sufficiently broad to provide coverage for necessary dental procedures. Third, she argues that even if only emergency dental care is covered by the plan, the Director abused his discretion in determining that the services she seeks do not qualify as emergency dental care. We reject each of these arguments and address them in turn.

A. Medicaid Does Not Require Arizona to Provide All Necessary Dental Services If It Decides To Provide Any Dental Service.

¶ 11 AHCCCS is Arizona's Medicaid program. Under Medicaid, Title XIX of the Social Security Act, see 42 U.S.C. § 1396 et seq. (2003), ("Act") the federal government provides matching funds to states to partially pay for state programs that provide "medical assistance" to recipients who qualify based on need. The Act defines the categories of "medical assistance" for which the federal government will pay matching funds. To participate in the Medicaid program the Act requires a state to provide designated categories of "medical assistance" to its plan participants.³ 42 U.S.C. § 1396a(a)(10). Other categories of medical assistance as defined by the Act, however, are optional. A state may, but need not, provide any of these optional services. 42 C.F.R. § 440.225 (1995) ("Any of the services defined in subpart A of this part . . . may be furnished under the State plan at the State's option.").

¶ 12 With respect to the "medical assistance" that a state must provide, the Act does not require that the "medical assistance" be provided to the extent needed by every individual recipient of benefits. Rather, states are allowed to place usage limitations on the assistance even if the limitations are inconsistent with an individual recipient's personal medical needs. See, e.g., 42 C.F.R. § 440.230(d) (permitting state plans to impose coverage limitations based on medical necessity and utilization review).

¶ 13 For example, in Alexander v. Choate, 469 U.S. 287, 309, 105 S.Ct. 712, 83 L.Ed.2d 661 (1985), the Supreme Court upheld the fourteen-day annual limit on inpatient hospital stays imposed by Tennessee's Medicaid plan even though the Act requires states to cover inpatient hospital services. The Supreme Court recognized that some patients would require more than fourteen days of inpatient services in a year but noted that Medicaid did not require that a state plan "guarantee that each recipient will receive that level of health care precisely tailored to his or her particular needs." Id. at 303, 105 S.Ct. 712. Rather, "the benefit provided through Medicaid is a particular package of health care services . . . . That package of services has the general aim of assuring that individuals will receive necessary medical care, but the benefit provided remains the individual services offered — not `adequate health care.'"⁴ Id.; see also Hope Med. Group for Women v. Edwards, 63 F.3d 418, 426 (5th Cir.1995) (holding that states may "choose to limit the provision of particular medical procedures or treatments as long as the restriction complies with [42 C.F.R. § 440.230]."); Hern v. Beye, 57 F.3d 906, 911 (10th Cir.1995) ("It may be that, pursuant to a generally applicable funding restriction or utilization control procedure, a participating state could deny coverage for a service deemed medically necessary in a particular case."); Miller v. Whitburn, 10 F.3d 1315, 1321 (7th Cir.1993) (upholding reasonable applications of exclusion for experimental treatments); Charleston Memorial Hosp. v. Conrad, 693 F.2d 324, 330 (4th Cir.1982) (approving limits on inpatient and outpatient stays because the authorized limit reasonably met the needs of the great majority of Medicare recipients); Curtis v. Taylor, 625 F.2d 645, 652 (5th Cir.1980) (upholding a state...