Muth v. Sebelius
| Decision Date | 13 March 2012 |
| Docket Number | Case No. SACV 10–01567–CJC(JEMx). |
| Citation | 856 F.Supp.2d 1127 |
| Parties | Jean MUTH, Plaintiff, v. Kathleen SEBELIUS as Acting Secretary of Health and Human Services; and Does 1 through 10, Defendants. |
| Court | U.S. District Court — Central District of California |
OPINION TEXT STARTS HERE
John Paulo Schafer, Manderson Schafer & McKinlay, Scott Howard Sims, Eagan Avenatti, LLP, Newport Beach, CA, Roxanna Hope Watrous, Bryan Cave LLP, Irvine, CA, for Plaintiff.
Marcus M. Kerner, AUSA–Office of U.S. Attorney, Santa Ana, CA, for Defendants.
On October 14, 2010, Plaintiff Jean Muth filed a complaint seeking review of the determination of Defendant Kathleen Sebelius, Secretary of Health and Human Services (“the Secretary”), that Ms. Muth's Medicare Advantage Plan (“MA plan”) provided by Aetna Medicare Golden Choice (“Aetna”) did not cover requested prosthodontal services. Ms. Muth's complaint specifically challenges the decision of the Medicare Appeals Council (“MAC”) agreeing with the Secretary and denying coverage of her claim. The parties appeared for oral argument on November 14, 2011, before Judge Andrew J. Guilford. After the hearing, Judge Guilford recused himself and the case was transferred to this Court. Upon review of the parties' papers, the administrative record, and the transcript of the hearing before Judge Guilford, the Court AFFIRMS the decision of the Secretary and the MAC.
Ms. Muth is a member of Aetna Medicare Golden Choice, a private insurer who contracts with Medicare to provide coverage for services to individuals eligible for Medicare. (Administrative Record (“A.R.”), at 6.) Ms. Muth's MA plan covers services that are covered under Medicare Part A and B, and she also has a dental rider with Aetna.1 ( Id.) As noted by the MAC, and undisputed by the parties, Ms. Muth has “a complex medical history, including breast and brain cancer, with radiation therapy, chemotherapy, and a mastectomy, all in 2007.” ( Id. at 7.) Ms. Muth also suffers from valvular heart disease. ( Id. at 35, 37.) In 2009, two years after Ms. Muth's cancer treatment, Ms. Muth's general dentist recommend she see a prosthodontist. The MAC explained in its decision that “[p]rosthodontics is the branch of dentistry dealing with replacement of missing teeth, as by bridges or artificial dentures.” ( Id.) (citing Webster's New World Dictionary 1080 (1988).) The administrative law judge (“ALJ”) held that Ms. Muth's dental problems were the result of chemotherapy and radiation.2 ( Id. at 9.)
In February of 2009, Ms. Muth received a referral to a prosthodontist for a “comprehensive prophylaxis, dental exam, full mouth x-ray, jaw joint x-rays, and a comprehensive treatment plan.” ( Id. at 7.) On April 15, 2009, Ms. Muth's primary care physician requested approval from Monarch Healthcare, Ms. Muth's primary care group, for the referral. Ms. Muth asserts that she requested coverage for not only this initial consultation, but also for the treatment itself.3 Monarch Healthcare initially denied the referral as an excluded dental service, and again denied coverage on internal appeal. ( Id.) Ms. Muth's case was referred to the Independent Review Entity for reconsideration, and her claim was again denied. ( Id. at 8.) Ms. Muth then sought review from the ALJ who determined that Aetna's terms of coverage, as set forth in the Evidence of Coverage (“EOC”), extended beyond the limits of Medicare coverage. ( Id. at 104.) The ALJ found that there was ambiguity in the MA plan as to whether Ms. Muth's prosthodontic services were covered, and construed that ambiguity against the MA plan. The ALJ also held that her teeth problems were a complication of mastectomy and covered under the Women's Health and Cancer Rights Act (“WHCRA”). “The ALJ ordered the MA plan to cover the requested consultation and treatment from a network prosthodontist under the plan's medical benefit, not the dental rider.” ( Id. at 9.)
The MA plan filed a request for review by the MAC. On August 10, 2010, the MAC reversed the decision of the ALJ. Specifically, the MAC held that the general Medicare dental exclusion, 42 U.S.C. § 1395y(a)(12), and related regulations and guidelines warranted denial of coverage. The MAC further held that the EOC clearly limited coverage to mirror Medicare, and the ALJ erroneously interpreted the EOC to provide coverage beyond that provided by Medicare. ( Id. at 17.) The MAC also held that Ms. Muth's dental problems were not a physical complication of mastectomy and, thus, not covered by the WHCRA. ( Id.) Finally, the MAC held that the ALJ improperly reached the issue whether treatment itself was covered.
The Court has the authority to review the Secretary's decision denying Plaintiff Medicare benefits pursuant to 42 U.S.C. §§ 405(g), 1395ff(b); Vista Hill Found., Inc. v. Heckler, 767 F.2d 556, 558 (9th Cir.1985). The Court has the authority to affirm, modify, or reverse the Secretary's decision “with or without remanding the cause for rehearing.” 42 U.S.C. 405(g). Here, the MAC's decision constitutes the Secretary's final decision. Id.;42 C.F.R. § 405.1130 () Under 42 U.S.C. § 405(g), the Secretary's final decision shall be disturbed only if the factual findings underlying the decision are not supported by substantial evidence or if the Secretary applied incorrect legal standards.“Substantial evidence is defined as more than a mere scintilla but less than a preponderance.” Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir.1999). “[A] court must ‘consider the record as a whole, weighing both evidence that supports and evidence that detracts from the Secretary's conclusion.’ ” Id. (quoting Penny v. Sullivan, 2 F.3d 953, 956 (9th Cir.1993)).
Where the Secretary interprets a statute, the Court must first consider “whether Congress has directly spoken to the precise question at issue.” Chevron U.S.A. v. Natural Res. Def. Council, Inc., 467 U.S. 837, 842, 843 n. 9, 104 S.Ct. 2778, 81 L.Ed.2d 694 (1984). If Congress has not directly addressed the precise question, Id. at 843, 104 S.Ct. 2778. “The court need not conclude that the agency construction was the only one it permissibly could have adopted to uphold the construction, or even the reading the court would have reached if the question initially had arisen in a judicial proceeding.” Id. at 843 n. 11, 104 S.Ct. 2778. Accordingly, the Court is to accord “considerable weight” to the Secretary's construction, and the Court must adopt the “principle of deference to administrative interpretations.” Id. at 844, 104 S.Ct. 2778. If the Secretary's “construction or application of the statute is arbitrary and capricious, or manifestly contrary to the statute, deference to the administrative interpretation is inappropriate.” Guadamuz v. Bowen, 859 F.2d 762, 768 (9th Cir.1988) (citing Chevron, 467 U.S. at 844, 104 S.Ct. 2778). An interpretation of a statute arrived at after formal adjudication, and contained in the adjudicator's decision, constitutes an interpretation by the Secretary entitled to Chevron deference. See Christensen v. Harris Cnty., 529 U.S. 576, 587, 120 S.Ct. 1655, 146 L.Ed.2d 621 (2000).
Ms. Muth's asserts that “[t]he MAC erred in holding that the Section 1395y(a)(12) exclusion applies” to Ms. Muth's case. Contrary to this assertion, the MAC did not improperly apply law in finding that this exclusion was applicable. Section 1395y(a)(12) excludes coverage “for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.” Like the Seventh Circuit, the Court finds that the statute itself is ambiguous. More specifically, the Court finds that the statute is ambiguous with respect to the meaning of the phrase “in connection with” as it relates to Ms. Muth's case. The Court must, therefore, determine whether the Secretary's interpretation, as set forth in the MAC's decision, is entitled to Chevron deference. Ms. Muth asserted that the exclusion did not apply to her because her requested prosthodontic treatment was “in connection with” her cancer. She based this assertion on the fact that the dental disease giving rise to the need for prosthodontic services was caused by her chemotherapy and radiation treatments. The MAC found that the requested services were not covered because the statute and related regulations look to the nature of the service performed, and not the cause of the condition for which services are sought, to determine whether the exclusion applies. The MAC held that Section 1395y(a)(12) “applies without regard to the cause of any dental problems” and noted that “[m]any medical conditions or treatment for those conditions adversely impact dental health.” (A.R., at 15.) The MAC explained that “Congress has not made an exception to the general dental exclusion for ‘medical’ causes of dental decay.” ( Id.) The MAC's interpretation is neither arbitrary and capricious nor manifestly contrary to the statute. In fact, the interpretation is consistent with and guided by the interpretation of the statute condoned by numerous other courts including another Central District of California court and the Seventh Circuit. See Wood v. Thompson, 246 F.3d 1026 (7th Cir.2001); Chipman v. Shalala, 90 F.3d 421 (10th Cir.1996); Maggio v. Shalala, 40 F.Supp.2d 137 (W.D.N.Y.1999); Bick v. Sec'y of Health and Human Servs., ...
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...services are incident to treatment of a medical condition." (MAC Dec. PageID.12.) This outcome is consistent with Muth v. Sebelius, 856 F. Supp. 2d 1127 (C.D. Cal. 2012). In Muth, the plaintiff had a complex medical history including breast and brain cancer and heart disease. She sought tre......