Jackson v. Stockdale, A042139

• Decision Date: 27 November 1989
• Docket Number: No. A042139,A042139
• Citation: 264 Cal.Rptr. 525,215 Cal.App.3d 1503
• Court: California Court of Appeals Court of Appeals
• Parties: Jane JACKSON, et al., Plaintiffs and Respondents, v. James STOCKDALE, et al., Defendants and Appellants.

Page 525

264 Cal.Rptr. 525

215 Cal.App.3d 1503

Jane JACKSON, et al., Plaintiffs and Respondents, v. James STOCKDALE, et al., Defendants and Appellants.

No. A042139.

Court of Appeal, First District, Division 2, California.

Nov. 27, 1989.

Review Denied Feb. 1, 1990.

Stephen E. Ronfeldt, Legal Aid Soc. of Alameda County, Oakland, Jane Perkins, Standley Dorn, Los Angeles, Kirk McInnis, Sarah Reynoso, Legal Aid Soc. of Marin County, San Rafael, for plaintiffs and respondents.

John K. Van de Kamp, Atty. Gen., Stephanie Wald, Supervising Deputy Atty. Gen., Winifred Y. Smith, Deputy Atty.

Gen., San Francisco, for defendants and appellants.

INTRODUCTION

KLINE, Presiding Judge.

Defendants California Health and Welfare Agency, James Stockdale, Acting Secretary of the Agency, State Department of Finance, and Kenneth Kizer, Director of the Department, appeal the issuance of a preliminary injunction by the Alameda County Superior Court, enjoining appellants "from denying Medi-Cal coverage of root canal treatments and laboratory processed crowns on posterior teeth of adult Medi-Cal recipients unless the requested treatment is not medically necessary or there is a less costly, alternative service that meets the patient's medical needs." At issue in this appeal are certain regulations issued by the agency denying coverage for the above treatments (Cal.Code Regs., tit. 22, § 51307, subds. (d)(4) and (5)) and whether such provisions are contrary to coverage provided under the Medi-Cal Benefits Program (Welf. & Inst.Code, § 14000 et seq.) for "[e]mergency and essential diagnostic and restorative dental services...." (Welf. & Inst.Code, § 14132, subd. (h).) ¹

We conclude the challenged regulations are contrary to the intent and language of the statute and so affirm the judgment of the superior court.

STATEMENT OF FACTS

Respondent Jane Jackson

Respondent Jackson is a Medi-Cal recipient. Her dentist, Dr. Mark Maberley submitted a "Treatment Authorization Request" (TAR) for a permanent laboratory processed crown for Jackson. ² Jackson suffers from Meniere's Syndrome, an inner ear disorder, which causes clamping of her jaw and grinding of her teeth. The grinding and clamping broke the cusp of one of her posterior teeth and displaced three subsequent temporary fills on that tooth. Dr. Maberley prescribed a permanent laboratory processed crown to restore and prevent further damage to the tooth. Dr. Maberley explained that extraction was not a viable or appropriate alternative. Since Medi-Cal would not authorize a partial denture for the missing tooth, "extraction will result in a loss of chewing ability and exacerbate decay and deterioration of her gums. Ms. Jackson, due to her condition, is already predisposed to gum problems which could lead to acute and chronic pain. Loss of a tooth will also cause tipping of the tooth behind it, increasing the likelihood of further cracking and creating a perpetual cycle of extraction and tipping." According to Dr. Maberley, insertion of a stainless steel crown onto Jackson's damaged tooth was "not a viable or appropriate alternative to a laboratory processed crown" for three reasons. "First, the stainless steel crown will not mold to Jane Jackson's tooth nearly as well as a laboratory processed crown. The fit is particularly important, since she continuously grinds and clenches her teeth. There is a strong probability that a stainless steel crown would not stay on her tooth for any extended period of time. Second, stainless steel crowns can act as plaque traps and as irritants to the gum. Jane Jackson has a tendency toward gum problems. Third, since [she] has many gold inlays, insertion of the stainless steel crown may cause galvanic shock."

Although Dr. Maberley stated that the laboratory processed crown was medically necessary and there were no other adequate alternatives, the Department of Health Services (DHS) initially denied coverage of the crown. Following an administrative appeal, the hearing officer determined that the challenged regulations (Cal.Code Regs., tit. 22, § 51307, subds. (d)(4) and (5)) were invalid and authorized the requested coverage in its "proposed decision." The Director of DHS rejected the

hearing officer's decision and denied coverage, citing the challenged regulation.

Respondent Linnea Kilgren

Respondent Kilgren, a Medi-Cal recipient, sought treatment for an acute infection of the gum surrounding a posterior tooth from her treating dentist, Dr. Thomas Jarvis. She was suffering intense pain and Dr. Jarvis believed that without treatment she would have suffered several days of intense pain and possible oral sinus infection which could have precipitated sufficient pressure on the optic artery to cause loss of her right eye. Therefore, Dr. Jarvis performed emergency root canal treatment. Dr. Jarvis explained that while extraction would have prevented the above problems or complications, "this would have caused a forward tilting of the second molar behind it. Because Ms. Kilgren grinds her teeth at night, the forward tilt would cause sideways pressure on her second molar against the opposing lower molars. It is more than likely this sideways force on the upper molar would eventually cause enough trauma to the tooth to cause the pulp tissue to necrose and eventually abscess." Based upon his experience and Kilgren's dental history, Dr. Jarvis stated that root canal therapy was "the only proper procedure" and was "medically necessary" because she would have lost at least one more tooth without the treatment.

DHS nonetheless denied coverage of the emergency root canal treatment.

Respondent Virginia Stockstill

Respondent Stockstill, a Medi-Cal recipient sought treatment from her dentist, Dr. Kimball Kaufman, for an impaired posterior tooth. Dr. Kaufman placed a temporary crown on the tooth to relieve Stockstill's "extreme discomfort." Dr. Kaufman submitted a TAR for a permanent crown, believing it to be " 'the only procedure which would adequately correct the impairment and prevent impairment of the claimant's oral health.' " Stockstill had already lost approximately four temporary crowns placed on this tooth. Dr. Kaufman stated that " 'the only adequate restoration would be a permanent crown. Extraction would result in a loss of chewing ability, forcing the next molar to tip, creating a perpetual cycle of extraction and tipping.' " Further, Dr. Kaufman opined that he had requested the permanent crown for Stockstill as he would have for a similarly situated private patient " 'because I believed it was the most appropriate procedure for [her].' " The proposed decision of the hearing officer held the challenged regulation invalid and authorized coverage. The DHS Director rejected this decision and denied coverage on the basis of the challenged regulation.

STATEMENT OF THE CASE

On December 19, 1985, respondents filed their complaint seeking to enjoin appellant agency's refusal to cover the dental services and seeking declaratory relief. Subsequently, the parties entered into a court approved stipulation in which DHS agreed to amend the challenged regulation to include coverage of medically necessary root canal treatment and laboratory processed crowns, subject to approval of the Department of Finance and the Office of Administrative Law. The stipulation also provided that respondents were to receive treatment regardless whether the agreed-upon amendments were approved. Pursuant to the stipulation, DHS submitted the amendments to the two agencies. In February 1987, appellant Department of Finance disapproved the proposed regulation as too costly. The Department of Finance estimated the change would result in "additional costs of approximately $460,000 ($230,000 General Fund)" annually.

On November 6, 1987, respondents moved for a preliminary injunction and writ of mandate. On February 25, 1988, the trial court enjoined appellants from denying Medi-Cal coverage of the dental services where the treatment is medically necessary, absent a less costly alternative that meets the patient's medical need. Appellants filed a timely notice of appeal. On October 3, 1988, this court denied respondents' writ seeking to lift the automatic

stay on the trial court's order. ³

ISSUES

Appellants challenge the issuance of the injunction. They contend: (1) Medi-Cal is only required to provide essential or emergency services "to the extent practicable;" (2) the Legislature did not intend to include root canal treatment or laboratory processed crowns as essential services under section 14132, subdivision (h); (3) the foregoing services are not emergency or essential services within the meaning of that section and Medi-Cal offers less costly alternatives; (4) Medi-Cal is currently providing benefits "to the extent practicable."

Respondents frame the central issue somewhat differently as whether the challenged regulation, by categorically excluding certain dental services from Medi-Cal coverage regardless of their medical necessity, violates the requirement of section 14132, subdivision (h), that emergency and essential dental services be covered.

I.

The Medi-Cal program is set forth in Welfare and Institutions Code section 14000 et seq. Section 14000 provides in relevant part:

"The purpose of this chapter is to afford to qualifying individuals health care and related remedial or preventative services, including related social services which are necessary for those receiving health care under this chapter.

"The intent of the Legislature is to provide, to the extent practicable, through the provisions of this chapter, for health care for those aged and other persons, including family persons who lack sufficient annual income to meet the costs of health care, and whose other assets are so limited that their application toward the costs of such care would jeopardize the person or family's future minimum self-maintenance and security. It is intended that whenever possible and...