Johnson v. Minnesota Dept. of Human Services

• Decision Date: 10 June 1997
• Docket Number: C7-96-2066,Nos. C5-96-2468,s. C5-96-2468
• Citation: 565 N.W.2d 453
• Parties: Forrest JOHNSON, Respondent, v. MINNESOTA DEPARTMENT OF HUMAN SERVICES, Appellant.
• Court: Minnesota Court of Appeals

Page 453

565 N.W.2d 453

Forrest JOHNSON, Respondent, v. MINNESOTA DEPARTMENT OF HUMAN SERVICES, Appellant.

Nos. C5-96-2468, C7-96-2066.

Court of Appeals of Minnesota.

June 10, 1997.

Syllabus by the Court

1. In an administrative proceeding to determine a person's entitlement to medical assistance funds for a health service, when the party requesting medical assistance establishes a prima facie case of eligibility for the funds, the burden of going forward with the evidence shifts to the opposing party, and if the opposing party fails to present evidence sufficient to rebut the prima facie case, the party requesting medical assistance has met the burden of proof.

2. When the commissioner of human services or the district court orders assistance or aid or services to be paid in a proceeding under Minn.Stat. § 256.045, subd. 10. (1996), only assistance or aid or services that are provided on a monthly basis must be paid or provided pending appeal of the order.

Steven P. Elliot, Minnesota Disability Law Center, Minneapolis, for Respondent.

Hubert H. Humphrey, III, Attorney General, Jacqueline Moen, Assistant Attorney General, Paul M. Landskroener, Assistant Attorney General, St. Paul, for Appellant.

Considered and decided by PETERSON, P.J., and LANSING and CRIPPEN, JJ.

OPINION

PETERSON, Judge.

The Minnesota Department of Human Services (Department) denied Forrest Johnson's request for prior authorization to use medical assistance funds to purchase a HiRider stand-up wheelchair. A chief appeals referee for the Commissioner of Human Services affirmed the Department's decision on grounds that Johnson failed to demonstrate that the HiRider was medically necessary and that it was the least expensive appropriate alternative health service available. On appeal to the district court, the district court concluded Johnson had established that the HiRider was medically necessary and the least expensive appropriate alternative. The Department now appeals from the district court order reversing the chief appeals referee's decision and from a second district court order directing the issuance of a writ of mandamus compelling the Department to immediately provide authorization for Johnson to obtain a HiRider. We affirm in part and reverse in part.

FACTS

Respondent Forrest Johnson, currently age 39, was diagnosed with multiple sclerosis (MS) in 1990. MS is a progressive disease that causes myelin, a fat that coats nerves, to degenerate, and an individual's symptoms depend on where the myelin loss occurs. In Johnson's case, MS has caused weakness and stiffness in his legs, making him unable to stand or walk without assistance. Johnson's treating physician, Dr. Shapiro, and Johnson's physical therapist, Sharon Ruhsam, testified that Johnson's symptoms were unusual in that despite the extreme weakness in Johnson's legs, he maintained a high level of cognitive functioning and the ability to use his arms, allowing him to continue living independently.

Dr. Shapiro testified that prolonged immobility of the human body causes many problems, including the nervous system and muscles atrophying, infections developing due to the breakdown of skin, loss of range of motion, and calcium leeching out of bones, making them more brittle and possibly causing urinary tract infections. Other evidence indicated that prolonged immobility may result in digestive problems. Dr. Shapiro testified that some of the complications resulting from prolonged immobilization require extensive and costly treatment. Passive standing can alleviate many of the problems caused by prolonged immobility, including bone calcium loss, urinary tract and bladder infections, muscle spasticity, muscle contractures, loss of range of motion, muscle atrophy, and decubitus ulcers. Passive standing also can improve bowel function, respiration, and circulation.

Johnson presented evidence that he has had urinary tract infections as a result of prolonged immobility and that his digestive system has been affected by prolonged immobility. Ruhsam and Johnson's occupational therapist, Ronna Linroth, stated that Johnson had an increased risk for bone demineralization because he used steroids to manage his MS and an increased risk for pressure ulcers because he had little padding over boney prominences and was unable to feel pain. Dr. Shapiro testified that both the likelihood of Johnson having complications from prolonged immobilization and the likelihood of passive standing lessening those complications were significant. Ruhsam and Linroth believed that passive standing would improve Johnson's respiration and significantly reduce his muscle spasticity. Ruhsam testified that passive standing would also improve Johnson's range of motion.

The HiRider is a combination power wheelchair and passive standing device that enables Johnson to move between sitting and standing positions by touching two buttons. Johnson testified that when he used the HiRider on a trial basis for about three months in 1995, his leg muscles became stronger, he did not have a bladder infection, and he noticed an improvement in his balance, muscle tone, digestion, and diaphragm function.

Linroth testified that the HiRider was the safest passive standing device for Johnson to use at home without another person assisting him:

[J]ohnson can set himself up in [other passive standing devices] in order to be lifted up in them. Our standing frames that we have there are hydraulic manual pumps and so he would not be able to pump himself up into that independently. In the stander, when it has the power lift that [Johnson] was alluding to earlier, there's like a toggle switch where you lift yourself up and he could probably run that toggle but what happens is because of the bracing his arm gets cut down here and he has to loop up around them so there's danger for injury for one thing, but the other part of that is the gate that you close behind you. You have to be able to turn around to get that gate if you were doing it yourself. If he is, has his feet planted and he's got extensor tone locking him in, he's not going to be able to rotate around like that to get that. And if he gets it, and by hook or crook, [Johnson] might figure out a way to do that, what happens when you go to release it then, it slides back away from you so that you just have the belt to catch you and getting back down then becomes a real safety issue.

Linroth believed that the HiRider would be cost-effective given Johnson's age and the fact that intervention was occurring during an early stage in the development of Johnson's MS. Linroth testified that out of 300 people seen at the MS Achievement Center during the last ten years, Johnson was the only one for whom the Center had recommended a HiRider.

Dr. Shapiro explained that to benefit from passive standing, Johnson would need to get into a standing position several times daily and that the HiRider would enable him to do so. Dr. Shapiro testified that other passive standing devices would not be practical for Johnson:

There are standing frames that you can get up and stand in just for yourself, but most of those are ... you need people around to put you into the frame and you need people to take you down off the frame and you can only be up in the standing frame for a period of fifteen to twenty minutes and then somebody has to put you down and you go off and do something and then somebody has to put you back up again to get that benefit. We have had [Johnson] up in the stand frame. In a group situation where you have a lot of people who are going to stand, standing frames are fine, but to do what we really want to do with him, that's not very practical.

Dr. Shapiro also testified that during the previous 18 years, he had followed over 2,500 MS patients and had written only two prescriptions for a standing type of wheelchair.

Ruhsam testified that the progression of Johnson's MS was making it increasingly difficult for him to transfer from a wheelchair to a standing device:

[E]ven though [Johnson's] talking about no problems with transfer, from my professional eye I am more and more concerned with that. Being able to have the HiRider, to me, would allow him an opportunity to decrease some of the transfers he has to do. Right now he's talking about five or six times a day he transfers. Every time he transfers and he's alone, he's at risk for falling as far as I can see.

Ruhsam testified that a HiRider would minimize the number of transfers Johnson would need to make daily. The evidence indicated that a passive standing device other than a HiRider would require Johnson to transfer between two devices. Ruhsam testified that a HiRider would not be cost-effective for someone with a home care aide because the aide could reposition the person. Ruhsam felt that a HiRider might enable Johnson to continue living independently without assistance from a personal care attendant for a longer period of time than would be possible otherwise.

The chief appeals referee found:

13. [Johnson's] physician and therapist argue that it is the community medical standard to prescribe a health service that reduces the effects of a medical condition--even though it may not eliminate them entirely. Dr. Shapiro prescribed the HiRider for [Johnson], and he did so as an expert in the treatment of multiple sclerosis. Dr. Shapiro has only written two prescriptions in the past eighteen years for stand-up wheelchairs, he asserts. Moreover, the HiRider was recommended by Ronna Linroth, occupational therapists, and Sharon Ruhsam, physical therapist, who treat [Johnson] at the MS Achievement Center.

[Johnson] is the only client out of three hundred, for whom these therapists have recommended a HiRider. They justify the departure in [Johnson's] case, as he is unique from other MS sufferers. He has superior cognitive skills and upper body strength and motor skills, whereas the majority of MS patients have weakened upper...