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STATE OF NORTH CAROLINA
COUNTY OF ROCKINGHAM
IN THE OFFICE OF
ADMINISTRATIVE HEARINGS
08 DHR 1035
______________________________________________________________________________
Linda F. Ellison,
Petitioner,
vs.
NC Department of Health and Human
Services and or EDS,
Respondent.
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DECISION
______________________________________________________________________________
THIS MATTER came on for hearing before the undersigned Shannon R. Joseph,
Administrative Law Judge, on June 27, 2008, in High Point, North Carolina.
APPEARANCES
For Petitioner:
Linda F. Ellison, Pro se.
For Respondent: Iain Stauffer
Assistant Attorney General
N.C. Department of Justice
ISSUE
Whether Respondent acted erroneously when it denied the prior approval request for
orthodontic services for Petitioner’s grandson, D.E.?
STATUTES AND RULES
42 U.S.C. § 1396 et seq.
N. C. Gen. Stat. Ch. 108A, Article 2, Parts 1 and 6
10A N.C.A.C. 22O.0301
EXHIBITS
Respondent’s exhibits 1 – 8 were admitted in evidence.
Petitioner’s exhibits 1-5 were admitted in evidence.
BASED ON careful consideration of the sworn testimony of the witnesses presented at
the hearing, along with documents and exhibits received and admitted in evidence and the entire
record in this proceeding, the Undersigned makes the following Findings of Fact. In making the
Findings of Fact, the Undersigned has weighed all the evidence and has assessed the credibility
of the witnesses by taking into account the appropriate factors for judging credibility, including
but not limited to the demeanor of the witnesses, any interests, bias, or prejudice the witness may
have, the opportunity of the witness to see, hear, know, or remember the facts or occurrences
about which the witness testified, whether the testimony of the witness is reasonable, and
whether the testimony is consistent with all other believable evidence in the case.
FINDINGS OF FACT
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1.
In December, 2007, Dr. N. Scott Duncan submitted a prior approval request for
orthodontic services to Electronic Data Systems (“EDS”) for Petitioner’s grandson, “D.E.” At
the time of the prior approval request, D.E. was a thirteen (13) year-old male.
2.
Petitioner’s request for prior approval stated that D.E. has a Class II skeletal
pattern, and a Class II Division I malocclusion, with primary problems consisting of a slight
anterior posterior misalignment and a minor anterior arch length discrepancy.
3.
Respondent is the agency responsible for administering North Carolina's medical
assistance (Medicaid) program.
4.
EDS is under contract with Respondent’s Division of Medical Assistance (DMA)
to provide independent medical consultation for certain utilization functions. One of those
utilization functions is the review of prior approval requests for orthodontia.
5.
An orthodontist employed by EDS reviewed D.E.’s request for prior approval for
this procedure. Based on this review, the EDS orthodontist classified D.E. as a Skeletal and
Dental Class I. The EDS orthodontist also determined that D.E. had mild upper and lower
crowding, a four millimeter overjet, an anterior cross-bite tendency at teeth numbers 7 and 27, a
one millimeter midline shift to the right, and a mild curve of the spee. Based on the information
submitted in the prior approval request, the EDS orthodontist determined that Petitioner’s
condition case does not meet Medicaid criteria for approval for orthodontic services. EDS
therefore denied the prior approval request at issue because medical necessity was not
demonstrated for the requested orthodontic service.
6.
Orthodontics is defined in the Division of Medical Assistance Clinical Coverage
Policy No.: 4B, Orthodontic Services (hereinafter “Policy 4B”), as a corrective procedure for
functionally handicapping conditions.
7.
Petitioner requested an informal appeal through the North Carolina Department of
Health and Human Services Hearing Office, which appeal was conducted on February 26, 2008.
The informal appeal upheld the EDS decision to deny prior approval.
8.
Sandra Parker, is employed with DMA as a Dental Policy Analyst. She reviews
prior approval requests and claims, participates in informal reviews, responds to telephone and
written inquiries and updates dental policy. She reviewed the medical documentation in this
case. In evaluating whether this procedure was medically necessary, she reviewed Medicaid’s
guidelines which are set forth in Policy 4B. These criteria are meant to indicate whether medical
necessity exists for orthodontic services. Evaluation of the criteria set forth in this policy and the
documentation submitted in support of the prior approval request shows that the request
submitted does not demonstrate that D.E. meets the necessity criteria. The Medicaid criteria for
when services are covered states that:
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The following criteria for functionally handicapping conditions apply when cases are
reviewed for N.C. Medicaid orthodontic approval. The probability for approval is
increased when two or more of the following criteria exist:
a.
b.
c.
d.
e.
f.
g.
h.
Severe skeletal condition (recipient’s age and the direction of growth are
also considered).
Occlusion (severe anterior/posterior, transverse, and vertical
discrepancies, crossbites with functional shifts).
Crowding must be moderate to severe and functionally intolerable over a
long period of time (e.g., occlusal disharmony and/or gingival stripping
secondary to severe crowding).
Overbite must be deep, complete, and traumatic.
Overjet (excessive protrusion 6+ mm).
Openbite (excessive 4 to 5 mm).
Psychological and emotional factors (e.g., psychosocial inhibition to the
normal pursuits of life).
Potential that all problems will worsen.
9.
Dr. Mark W. Casey is a licensed dentist in the State of North Carolina and
Florida. He is the Dental Director for the Division of Medical Assistance, North Carolina
Department of Health and Human Services and has been in that position for one and a half years.
He graduated from the University of North Carolina School of Dentistry at Chapel Hill. He first
became licensed in Florida in 1988 and in North Carolina in 2005. Dr. Casey was a clinical
dentist for eighteen (18) years. He is an expert in the field of dentistry.
10.
Dr. Casey reviewed the medical documentation submitted in connection with the
request for prior approval in this case, including the documentation, panoramic and
cephalometric x-rays, and study models made from molds of D.E.’s teeth that show the bite.
D.E.’s skeletal and dental relationship are Class I, which is in the normal range. D.E. has only
mild upper and lower crowding, a 4 millimeter overjet, no overbite, and no openbite. Dr. Casey
noted that these findings do not meet the Medicaid criteria as enunciated in Policy 4B. Dr.
Casey noted that there was no supporting documentation to support a conclusion that
psychological and emotional factors were inhibiting D.E.’s normal pursuits of life, and there was
no supporting documentation to show that potential existed for the problems to worsen.
11.
Dr. Casey explained that D.E.’s four millimeter overjet was caused by the rotation
of one tooth: tooth number 8. The overjet measurement for the remainder of D.E.’s teeth is
approximately 1-2 millimeters.
12.
Dr. Casey further noted that Dr. Duncan provided that D.E. was a Class II
skeletally, but that Dr. Duncan did not classify the condition as severe. A skeletal condition
classified as Class II may be mild to severe.
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13.
According to the documentation submitted with the prior approval request, Dr.
Casey found that D.E. did not have a severe skeletal or dental condition, did not have moderate
or severe crowding, had a normal overbite relationship, had a four millimeter overjet which is
not an excessive overjet, and had no openbite. There was no documentation to support a
conclusion that psychological and emotional factors were inhibiting D.E.’s normal pursuits of
life and no documentation that potential existed for the problems to worsen. Accordingly, it was
Dr. Casey’s opinion that, based on the information submitted in the prior approval request,
D.E.’s condition did not meet the Medicaid criteria for orthodontia.
14.
Further, Section 4.2 of Policy 4B provides criteria for types of cases that are not
eligible for approval. Dr. Casey’s opinion is that criterion “h” applied here because D.E.’s
condition was a localized tooth alignment problem which required a relatively short period of
treatment.
15.
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal
Medicaid requirement that requires the state Medicaid agency to cover services, products or
procedures for Medicaid recipients under 21 years of age if the service is medically necessary
health care to correct or ameliorate a defect, physical or mental illness, or a condition identified
through a screening examination.
16.
Dr. Casey also reviewed the request for prior approval under the medical
necessity standard set forth in EPSDT. In his opinion, the orthodontics requested in this case is
not medically necessary to correct or ameliorate D.E.’s condition. There was no evidence that
his condition is a functional impairment and or that it interferes with his ability to chew, his
ability to speak, prevents his ability to maintain good dental hygiene, and there is no pain noted.
17.
D.E.’s grandmother, Linda Ellison testified that she believes that D.E. suffers
from emotional problems due to the condition of his teeth. There was no evidence, however, that
D.E. has been seen or treated by a doctor or mental health professional for these emotional
problems and, there was no evidence from a licensed mental health professional diagnosing this
condition.
BASED ON the foregoing Findings of Fact, the Undersigned makes the following:
CONCLUSIONS OF LAW
1.
The Office of Administrative Hearings has personal and subject matter
jurisdiction of this contested case. The parties received proper notice of the hearing in this
matter. To the extent that the Findings of Fact contain Conclusions of Law, or that the
Conclusions of Law are Findings of Fact, they should be so considered without regard to the
given labels.
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2.
The burden of proof is on Petitioner to show that the requested orthodontic
service is medically necessary and that D.E. meets the legal requirements to receive prior
approval from Respondent for these services. Overcash v. N.C. Dep't of Env't & Natural
Resources, 179 N.C. App.697, 699, 635 S.E.2d 442, 444-45 (2006) ("[C]ontrolling case law
places the burden of proof on the petitioner in an administrative contested case proceeding to
prove that he is entitled to relief from an agency decision . . . ."), disc. review denied, 361 N.C.
220, 642 S.E.2d 445 (2007).
3.
Based on the preponderance of the evidence, Petitioner has failed to meet her
burden of proof.
4.
Respondent has shown and the Court concludes that neither the documentation
submitted with request for prior approval nor the evidence presented at hearing demonstrates that
the requested orthodontic service is medically necessary for petitioner D.E. at this time or that
D.E. has a functional impairment.
5.
Pursuant to N.C. Gen. Stat. § 150B-34, based on the preponderance of the
evidence and “giving due regard to the demonstrated knowledge and expertise of the agency with
respect to facts and inferences within the specialized knowledge of the agency,” Respondent did
not act erroneously.
BASED ON the foregoing Findings of Fact and Conclusions of Law, the Undersigned
makes the following:
DECISION
Respondent has not acted erroneously in its denial of orthodontic services and its decision
is affirmed.
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NOTICE
The agency making the final decision in this contested case is required to give each party
an opportunity to file exceptions to this decision issued by the Undersigned, and to present
written arguments to those in the agency who will make the final decision. N. C. Gen. Stat. §
150B-36(a). In accordance with N.C. Gen. Stat. § 150B-36 the agency shall adopt each finding
of fact contained in the Administrative Law Judge's decision unless the finding is clearly
contrary to the preponderance of the admissible evidence. For each new finding of fact made by
the agency that is not contained in the Administrative Law Judge's decision, the agency shall set
forth separately and in detail the evidence in the record relied upon by the agency in making the
finding of fact. The agency shall adopt the decision of the Administrative Law Judge unless the
agency demonstrates that the decision of the Administrative Law Judge is clearly contrary to the
preponderance of the admissible evidence in the official record. The agency that will make the
final decision in this case is the North Carolina Department of Health and Human Services.
IT IS SO ORDERED.
This the 9th day of July, 2008.
___________________________
Shannon R. Joseph
Administrative Law Judge
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