Detgen v. Janek

• Decision Date: 13 March 2013
• Docket Number: Civil Action No. 3:11–CV–2974–G.
• Citation: 945 F.Supp.2d 746
• Parties: Scott DETGEN by his next friend L.C. DETGEN, et al., Plaintiffs, v. Dr. Kyle JANEK, in his official capacity as Executive Commissioner, Texas Health and Human Services Commission, Defendant.
• Court: U.S. District Court — Northern District of Texas

945 F.Supp.2d 746

Scott DETGEN by his next friend L.C. DETGEN, et al., Plaintiffs,

v.Dr. Kyle JANEK, in his official capacity as Executive Commissioner, Texas Health and Human Services Commission, Defendant.

Civil Action No. 3:11–CV–2974–G.

United States District Court,

N.D. Texas,

Dallas Division.

March 13, 2013.

Maureen Colette O'Connell, Southern Disability Law Center, Austin, TX, Lewis Golinker, Law Offices of Lewis Golinker, Ithaca, NY, Susan D. Motley, Disability Rights Texas, Dallas, TX, for Plaintiffs.

Erika M. Kane, Office of the Texas Attorney General, Austin, TX, for Defendant.

MEMORANDUM OPINION AND ORDER

A. JOE FISH, Senior District Judge.

Before the court are the cross-motions for summary judgment of the plaintiffs and the defendant (docket entries 37 and 39). For the reasons stated below, the plaintiffs' motion is denied and the defendant's motion is granted.

I. BACKGROUND

A. Factual Background

Scott Detgen (“Detgen”), Juanita Barazza (“Barazza”), Brandon Doyel (“Doyel”), and Joshua Vargas (“Vargas”) (collectively, the “plaintiffs”) bring this suit because the defendant, Dr. Kyle Janek (“Janek”), acting in his official capacity as the Executive Commissioner of the Texas Health and Human Services Commission (“HHSC”), and his agents, the Texas Medicaid and Healthcare Partnership (“TMHP”) and Superior Health Plan, denied the plaintiffs' claims for Medicaid benefits for a particular type of ceiling lift, an item of medical equipment used to transfer a patient to and from bed, bath, wheelchair, and other surfaces.

1. Scott Detgen

Detgen is a 28 year old resident of Rockwall County, Texas. See Second Amended Complaint (“Complaint”) ¶ 11 (docket entry 25); Plaintiffs' Sealed Appendix in Support of Motion for Summary Judgment (“Plaintiffs' Sealed Appendix 1”), Ex. 27 Detgen Affidavit (“Aff.”) ¶ 5 at 83 (docket entry 42). He receives Supplemental Security Income (“SSI”) due to his disability and is categorically-eligible for the Texas Medicaid program. See Complaint ¶ 11. Detgen was diagnosed with cerebral palsy at birth and has numerous medical conditions including quadriplegia, legal blindness, seizure disorder, severe contractures, and a history of hip dislocation. Plaintiffs' Sealed Appendix 1, Ex. 27 Detgen Aff. ¶ 2 at 83. He is incontinent of bowel and bladder and is dependent upon his caregivers to meet his personal care needs. Id. ¶¶ 3–4 at 83. He is 5 feet 2 inches tall and weighs approximately 95 pounds. Id. ¶ 5 at 83. Detgen is unable to walk, bear weight, sit independently, or assist with repositioning or transferring, and he must be manually transferred by one or both of his parents from his bed to the floor, to and from the bathtub, and to a stair lift that is used to move him between the first and second floors of his house. Id. ¶¶ 4, 6 at 83. These transfers are necessary for Detgen to maintain his hygiene and to prevent skin breakdown. Id. ¶ 3 at 83.

To assist with the process of transfers, Detgen's mother contacted a lifting specialist with a Medicaid-enrolled equipment provider to find a patient lift that would best alleviate Detgen's total dependence on caregivers for transfers. Id. ¶ 9 at 84. A ceiling lift was identified as the type of lift that could meet Scott's transfer needs in the three locations of his home for which transfers were required (bedroom, bathroom, and stairway). Id. The provider specifically identified a ceiling lift known as the “Roomer 5200,” which moves along a track that runs across the ceiling and allows the user to move from bedroom to bathroom or other designated locations in the home without additional transfers. Id. ¶ 10 at 84.

On October 26, 2010, United Rehab Specialists, Inc., the provider of the Roomer 5200, submitted a request for prior authorization of the recommended ceiling lift to TMHP. Id. Exhibit 28 at 86–92. On October 29, 2010, TMHP issued a denial notice that stated, in relevant part:

You have asked for an overhead lift system for your home. An overhead lift must be attached to the ceilings in your home. Attaching the lift to a ceiling is a structural change to your home. Equipment that requires a structural change to the home is a home modification. Texas Medicaid does not receive federal financial participation for home modifications because home modifications are not listed as Medicaid benefits under Section 1905a of the Social Security Act. Because Texas Medicaid does not get federal financial participation for home modifications your request cannot be approved.

Id. Exhibit 29 at 93–94.

A Medicaid fair hearing was requested on Detgen's behalf on November 15, 2010, to challenge TMHP's application of this policy exclusion to Detgen's request. Id. Ex. 27, Detgen Aff. ¶ 15 at 84. The hearing was held on April 13, 2011, before an HHSC hearing officer. The hearing decision was issued by HHSC on August 25, 2011, and concluded that “TMHP correctly denied Appellant's request for an overhead lift system” in accordance with agency policy. Id. Ex. 30 at 95–111.

2. Juanita Barraza

Barraza is a 45 year old Medicaid recipient in the state of Texas. Id. Ex. 31, Villareal Aff. ¶ 3 at 112. She has a history of long-standing medical conditions and disabilities, beginning at age 2 when she contracted measles and sustained brain damage. Id. As a result of this, Barraza lost the ability to walk and talk and was later diagnosed with a significant intellectual disability. Id. Several years later, she regained the ability to walk and continued to be ambulatory, albeit with a somewhat impaired gait. Id. In 2010,¹ Barraza experienced a number of ischemic strokes that left her completely non-ambulatory; she was subsequently diagnosed with paralysis due to cerebral atrophy. Id. ¶ 4 at 112.

Barraza lives at home with her mother who is her primary caregiver. Id. ¶ 2 at 112. Following Barraza's return home from hospitalization in late 2010, and after Villareal's assessment that the floor lift the hospital had ordered could not be used safely, a lifting specialist with a Medicaid-enrolled provider met with Barraza and her mother. Id. ¶¶ 7–8 at 112. The purpose of the meeting was to determine a lifting solution that would best address Barraza's transfer needs, given her complete dependence on her caregiver during transfers to and from her bed and bath and the physical limitations of her living space. Id. ¶ 8 at 112. A ceiling lift was identified as an appropriate solution for safely transferring Barraza both in and out of bed and bath. Id.

In February 2011, a request for prior authorization of a ceiling lift was submitted to TMHP on Barraza's behalf. Id. Ex. 32 at 114–123. On February 11, 2011, TMHP denied Barraza's request for a ceiling lift, using precisely the same language quoted above from its letter to Detgen. Id. Ex. 33 at 127. A Medicaid fair hearing was requested on Barraza's behalf in March 2011 to challenge the application of HHSC's policy to Barraza's prior authorization request for a ceiling lift. Id. Ex. 31 Villareal Aff. ¶ 11. The hearing was held on July 11, 2011, and a decision was issued on August 31, 2011. Id. ¶¶ 11–12. The hearing officer issued a single conclusion of law, stating that:

The Texas Medicaid Provider Procedure Manual instructs home health providers to obtain prior authorization for all durable medical equipment; moreover, as a state-contracted provider of home health services United Rehab Services must follow the most current instructions issued by the TMHP regarding requests for durable medical equipment. In this instance, United Rehab Services failed to follow the most current instructions issued in Texas Medicaid Bulletin 232 which specifically stated that “patient lifts requiring attachment to walls, ceilings, and floors” were not a covered item of Texas Medicaid benefits; therefore, the TMHP denial was correct.

Id. Ex. 34 at 143 (emphasis in original).

3. Brandon Doyel

Doyel is a 35 year old Texas resident and Medicaid recipient, born prematurely and, at 18 years old, diagnosed with quadriplegia, secondary to cerebral palsy. Id. Ex. 35, Doyel Aff. ¶ 2 at 145. As a result of his medical condition, Doyel is unable to walk and has used a power wheelchair for mobility since he was 4 years old. Id.Doyel is 5 feet 10 inches tall and weighs approximately 170 pounds. Id. ¶ 3.

Doyel lives alone and requires assistance with activities of daily living from personal care providers, including physical assistance with all transfers throughout the day. Id. ¶ 4. Doyel's daily transfer needs include transfers from bed to wheelchair, wheelchair to toilet, wheelchair to bathtub, and wheelchair to standing frame. Id. These numerous transfers are performed manually by Doyel's personal care providers. Id. Doyel has taken steps to reduce his daily number of transfers, including the use of a catheter to avoid transfers to the toilet. Id. ¶ 7. He also has foregone the use of a “stander” on a daily basis, because his care providers cannot safely transfer him into the device. Id.

In December 2010, a lifting specialist with a Medicaid-enrolled provider met with Doyel to determine a lifting solution that would best address his transfer needs. Id. ¶ 8. A ceiling lift was identified as an appropriate solution for transferring Doyel throughout the day. Id. In early February 2011, a request for prior authorization of a ceiling lift was submitted to TMHP on Doyel's behalf. Id. ¶ 10 at 146. On February 9, 2011, TMHP denied Doyel's request, using precisely the same language as in its denial of Detgen's request, quoted above. Id. Ex. 37 at 160. On April 11, 2011, a Medicaid fair hearing was requested on Doyel's behalf, to challenge TMHP's denial of the request for a ceiling lift. Id. Ex. 35 ¶ 11 at 146. The hearing was held on July 20, 2011. Id. On March 7, 2012, the hearing officer issued a decision upholding TMHP's denial, finding the ceiling lift was an “expense that is not a benefit of Home Health services.” Id. Ex. 38 at 164–65. The hearing officer...