Carondelet Health Services v. Arizona Health Care Cost Containment System Admin.

• Decision Date: 21 February 1995
• Docket Number: CA-CV,No. 2,2
• Citation: Carondelet Health Services v. Arizona Health Care Cost Containment System Admin., 897 P.2d 1388, 182 Ariz. 502 (Ariz. App. 1995)
• Parties: CARONDELET HEALTH SERVICES, dba St. Mary's Hospital, Plaintiff/Appellee, v. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION, an agency of the State of Arizona; and Dr. Leonard Kirschner, in his capacity as Director, Defendants/Appellants. 94-0320.
• Court: Arizona Court of Appeals

Page 1388

897 P.2d 1388

182 Ariz. 502

CARONDELET HEALTH SERVICES, dba St. Mary's Hospital, Plaintiff/Appellee, v. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION, an agency of the State of Arizona; and Dr. Leonard Kirschner, in his capacity as Director, Defendants/Appellants.

No. 2 CA-CV 94-0320.

Court of Appeals of Arizona Division 2, Department A.

Feb. 21, 1995.

Review Denied July 11, 1995. ^*

[182 Ariz. 503] Gammage & Burnham P.L.C. by Richard B. Burnham and Cameron C. Artigue, Phoenix, for plaintiff/appellee.

Johnston Maynard Grant and Parker, P.L.C. by Catherine M. Dodd and Anne C. Longo, Phoenix, for defendants/appellants.

OPINION

FERNANDEZ, Judge.

Arizona Health Care Cost Containment System (AHCCCS) Administration appeals from the superior court's reversal of an order of the AHCCCS director adopting the findings and conclusions of the administrative hearing officer following a hearing. AHCCCS had denied St. Mary's claim for emergency medical services rendered. Because there was evidence supporting the administrative ruling, we vacate the superior court's ruling and reinstate the administrative ruling.

The patient, a 50-year-old male, had been diagnosed with liver cancer approximately two years prior to his hospitalization. Following chemotherapy he was much improved and treatment was discontinued. Fourteen months later, on April 4, 1990, a chest x-ray revealed multiple nodules in both lungs and a deterioration of his liver functions. On April 11, 1990, the patient was admitted to appellee Carondelet Health Services, St. Mary's Hospital, in Tucson. The patient was found ineligible for coverage under AHCCCS at admission because his income exceeded the eligibility limits and required a spend down. On April 12, 1990, the patient incurred hospital expenses qualifying him for AHCCCS, effective April 15, 1990. Once qualified, the patient then became AHCCCS eligible for the April 11-14 period on a fee-for-service basis, but only for emergency medical services. A.R.S. §§ 36-2908, 2909(A).

St. Mary's contended that the services rendered during that three-day period were emergency services and submitted a claim for reimbursement. AHCCCS denied St. Mary's claim, acknowledging that while the services were medically necessary, they did not fall within the definition of emergency medical services pursuant to Ariz.Admin.Code R9-22-101(45), ¹ which states that:

"Emergency medical services" means services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

a. Placing the patient's health in serious jeopardy;

b. Serious impairment to bodily functions; or

c. Serious dysfunction of any bodily organ or part.

That definition was created by the AHCCCS director pursuant to his authority under A.R.S. § 36-2908(E). ²

In denying the claim, the AHCCCS hearing officer found as follows:

6. The testimony and case record establish that when the patient was admitted to the hospital, he was admitted for elective surgery. While there certainly was some sense of urgency, and the admission was medically necessary, considering the definition of emergency medical services in A.A.C. R9-22-101.38, as well as the definitions of emergency listed above in Thompson v. Sun City Community Hospital, Inc., [141 Ariz. 597, 688 P.2d 605 (1984) ] this admission was not unforeseen, was not sudden, and the absence of immediate medical attention would not have placed the patient's health in serious jeopardy. Thus, the services provided to the patient were not emergency medical services.

St. Mary's appealed to the superior court, which granted St. Mary's motion for summary judgment, finding the administrative decision was arbitrary, capricious, and an abuse of discretion. The superior court acknowledged that although the patient's condition before admission may not have met the rule's requirement of "sudden onset," it did require prompt action.

ADMINISTRATIVE REVIEW

In appeals taken under the Administrative Review Act, A.R.S. §§ 12-901 to 12-914, neither the superior court nor the court of appeals weighs the evidence; rather in reviewing factual determinations, the role of either court is only to determine whether there was substantial evidence to support the administrative decision. A.R.S. § 12-910; Siegel v. Arizona State Liquor Board, 167 Ariz. 400, 807 P.2d 1136 (App.1991). The fact that the court made its determination by summary judgment does not change the nature of the review, Havasu Heights Ranch and...