Luna v. Division of Social Services

• Decision Date: 06 January 2004
• Docket Number: No. COA02-557.,COA02-557.
• Citation: 589 S.E.2d 917,162 NC App. 1
• Parties: Benito LUNA, by personal representative, Mary JOHNSON, Petitioner v. DIVISION OF SOCIAL SERVICES and Division of Medical Assistance, North Carolina Department of Health and Human Resources, Respondents.
• Court: North Carolina Court of Appeals

589 S.E.2d 917

162 NC App. 1

Benito LUNA, by personal representative, Mary JOHNSON, Petitioner v. DIVISION OF SOCIAL SERVICES and Division of Medical Assistance, North Carolina Department of Health and Human Resources, Respondents.

No. COA02-557.

Court of Appeals of North Carolina.

January 6, 2004.

Turner, Enochs & Lloyd, P.A., by Melanie M. Hamilton, Thomas E. Cone, and Wendell H. Ott, Greensboro, for petitioner-appellant.

Attorney General Roy Cooper, by Assistant Attorney General Grady L. Balentine, Jr., for respondent-appellants.

HUDSON, Judge.

Petitioner appeals from an order entered by the superior court, which affirmed the denial of Medicaid coverage. The sole question presented to us is whether the Department correctly applied the law in determining that certain care and services did not constitute treatment for Petitioner's emergency medical condition. For the following reasons, we reverse.

Background

On 26 December 1999, petitioner Benito Luna, an undocumented immigrant from Mexico, arrived at the emergency room at Moses Cone Hospital in Greensboro, North Carolina, complaining of weakness and numbness in the lower extremities, erectile dysfunction, and bladder hesitancy. He was admitted to the hospital that same day for xrays and an MRI of his thoracic spine. The MRI revealed an intramedullary spinal cord tumor at the T6 level, and doctors originally diagnosed petitioner as having "medullary non-Hodgkin's lymphoma," and later clarified the diagnosis as "thoracic myelopathy with monoplegia in the lower limb and a malignant spinal cord neoplasm." On 28 December 1999, Luna underwent a thoracic laminectomy and resection of the spinal cord tumor.

After the surgery, the petitioner was gradually mobilized and, on 3 January 2000, the hospital transferred him to its rehabilitation unit for a comprehensive rehabilitation program. At the time of petitioner's transfer, 3 January 2000, his diagnosis was the same as in December. During petitioner's ten-day period in the rehabilitation service, the consulting oncologist noted that he had no signs of other disease, but believed that he had a primary central nervous system lymphoma. The pathology report confirmed this diagnosis. The doctor recommended "immediate" treatment to include high doses of chemotherapy.

On 14 January 2000, the rehabilitation service administered a Port-A-Cath to prepare petitioner for chemotherapy, and then transferred him to the hospital's oncology unit for intravenous chemotherapy. The oncology service then administered the treatment from 14 January through 24 January 2000, when petitioner was released to go home. Because the chemotherapy agent used in the course of petitioner's treatment was highly toxic at the doses used, it had to be administered on an inpatient basis. After 24 January 2000, petitioner was readmitted to the hospital for the remaining doses of the chemotherapy treatment plan.

On 28 April 2000, petitioner applied to the Rockingham County Department of Social Services for Medicaid benefits to cover the above admissions. Petitioner gave Moses Cone Hospital permission to act on his behalf and Mary Johnson of Moses Cone Hospital pursued his application for Medicaid benefits.

The Rockingham County DSS ("DSS") approved Medicaid coverage for the first few days of petitioner's initial hospitalization, 26 December 1999 up to 3 January 2000, during which time petitioner underwent the thoracic laminectomy and spinal cord tumor surgery. However, DSS denied Medicaid coverage for all treatment beginning 3 January 2000, determining that it was not for the treatment of a emergency medical condition. Petitioner then appealed to respondent North Carolina Department of Health and Human Services ("the Department"), which held a hearing, and on 23 February 2001, affirmed the decision of Rockingham County DSS. On 26 March 2001, petitioner filed a petition for judicial review in the superior court pursuant to G.S. § 108A-79(k) and Article 4 of Chapter 150B. On 14 December 2001, after hearing arguments from both parties, the superior court affirmed the respondent's final agency decision. Petitioner appeals.

Analysis

This Court's review of the superior court's order on appeal from an administrative agency decision generally involves "(1) determining whether the trial court exercised the appropriate scope of review and, if appropriate, (2) deciding whether the court did so properly." Amanini v. N.C. Dept. of Human Resources, 114 N.C.App. 668, 675, 443 S.E.2d 114, 118-19 (1994). In Amanini, this Court said that "our review of a trial court's order under G.S. § 150B-52 is the same as in any other civil case—consideration of whether the court committed any error of law." Amanini, 114 N.C.App. at 675, 443 S.E.2d at 118-119 (internal quotations and citations omitted); see also G.S. § 150B-43, et. seq. (2001). G.S. § 150B-52, as amended effective 1 January 2001, now provides that, in cases that are not governed by the amended G.S. § 150B-51(c), "[t]he scope of review to be applied by the appellate court under this section is the same as it is for other civil cases." Put a different way, in other civil cases, in which the superior court sits without a jury,

the standard of review is whether there was competent evidence to support the trial court's findings of fact and whether its conclusions of law were proper in light of such facts. Findings of fact by the trial court in a non-jury trial ... are conclusive on appeal if there is evidence to support those findings. A trial court's conclusions of law, however, are reviewable de novo.

Shear v. Stevens Building Co., 107 N.C.App. 154, 160, 418 S.E.2d 841, 845 (1992) (internal citations omitted). Here, however, petitioner has not assigned error to any of the findings of fact, which are thus binding. Thus, pursuant to G.S. § § 150B-51 and 108-79(k), we proceed to review the trial court's conclusions of law de novo. See id.

A.

"Medicaid is a federal program that provides health care funding for needy persons through cost-sharing with states electing to participate in the program." Greenery Rehabilitation Group, Inc. v. Hammon, 150 F.3d 226, 227 (2nd Cir.1998). A state that chooses to participate in the Medicaid program is required to follow certain federal regulations. In North Carolina, the General Assembly empowered the Department to establish a state Medicaid program, which is administered by county departments of social services under rules adopted by the Department. G.S. §§ 108A-54 and 108A-25.

The Department's rules regarding eligibility for Medicaid benefits, which are nearly identical to their federal counterparts, provide that "undocumented aliens or aliens not otherwise permanently residing in the United States under color of law generally are not entitled to full Medicaid coverage." N.C. Admin. Code tit. 10, r. 50B.0302 (June 2002); see also 42 U.S.C. 1396b (v)(1), (3). The only exception to this exclusion in both the North Carolina rule and the federal regulations is that payment is authorized for medical "care and services" that are necessary for the treatment of an emergency medical condition. Greenery, 150 F.3d at 227-28.

The implementing federal regulation provides, however, that undocumented aliens are entitled to Medicaid coverage for emergency services required 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: (i) placing the patient's health in serious jeopardy; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part. 42 C.F.R. § 440.255(b). A state Medicaid plan must conform to these requirements. 42 U.S.C. § 1396a(a).

The North Carolina rule provides coverage:

(c) ... for care and services necessary for the treatment of an emergency condition if:

(1) The alien requires the care and services after the sudden onset of a medical condition (including labor and delivery) that manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could 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.

N.C. Admin. Code tit. 10, r. 50B.0302 (June 2002). Thus, North Carolina's rules regarding eligibility for Medicaid coverage are plainly consistent with the federal requirements.

B.

Here, the parties do not dispute that on 26 December 1999, petitioner presented at the hospital with an emergency medical condition. Indeed, the surgical part of the treatment was covered and paid by Medicaid and is not at issue. The issue, rather, is whether the rest of the treatment, the chemotherapy and related services, should have been covered as well. Petitioner contends that we should focus on the term "treatment," and argues that "`treatment' is more extensive than, and covers a broader range of services than, providing emergency services or just those necessary for the stabilization of a patient's emergency medical condition." The Department, on the other hand, argues that the denial was proper.

The pertinent findings of the court are as follows:

3. Petitioner originally presented himself to the emergency room at Moses Cone Hospital on 26 December 1999 complaining of weakness and numbness in the lower extremities, erectile dysfunction and bladder hesitancy; he was admitted from the emergency room.

4. Petitioner was diagnosed as having medullary non-Hodgkin's lymphoma.

5. On 28 December 1999 Petitioner underwent a thoracic laminectomy and resection of a spinal cord tumor.

6. On 3 January 2000 Petitioner was transferred to the hospital's rehabilitation service for a comprehensive rehabilitation program.

7. On 14 January 2000 a Port-A-Cath was placed to prepare the Petitioner for chemotherapy,

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