NORTH CAROLINA IN THE OFFICE OF

ADMINISTRATIVE HEARINGS

COUNTY OF HOKE 02 DHR 2256

GLORIA HOWARD )

Petitioner, )

)

v. ) DECISION

)

NORTH CAROLINA DEPARTMENT OF )

HEALTH AND HUMAN SERVICES )

Respondent. )

______

On April 15, 2003, Administrative Law Judge Beecher Gray heard this contested case in Fayetteville, North Carolina. The Petitioner appeared pro se. The Respondent was represented by Belinda A. Smith, Assistant Attorney General.

ISSUE

Whether Petitioner’s prior approval request was for medically necessary reconstructive surgery.

APPLICABLE LAW AND AUTHORITY

Social Security Act, Title XIX

North Carolina Medicaid State Plan

10 N.C.A.C. 26C.0005; 26B.0101

N. C. State Plan for Medical Assistance

N. C. Medicaid Manual, Physician Services

FINDINGS OF FACT

1. Petitioner has a 1 centimeter hypoplastic scar with hyper pigmentation on the upper lip. She also has a 2.5 centimeter hypoplastic scar with hyper pigmentation to the chin area.

2. On July 25, 2002, Petitioner requested prior approval from Respondent to have an adjacent tissue transfer to her lip and chin in order to alleviate pain and discomfort and correct deformities.

3. July 29, 2002, Respondent denied the prior approval request based upon the lack of medical necessity.

4. Petitioner’s medical records show that the deformity is loss of pigmentation. The records do not contain clinical findings of pain and discomfort.

5. The surgery that Petitioner sought is cosmetic rather than reconstructive.

CONCLUSIONS OF LAW

1. The parties are properly before the Office of Administrative Hearings (“OAH”), and OAH has subject matter jurisdiction in this contested case.

2. All medical services paid for by Respondent must be medically necessary.

3. Reconstruction surgery is any surgical procedure performed to raise a patient to her optimum functioning level. Although the surgical procedure may have inherent cosmetic effects, it must be primarily considered to be reconstructive in nature.

4. Respondent does not pay for cosmetic surgery.

5. The surgery that Petitioner sought is cosmetic rather than reconstructive. Respondent correctly denied prior approval for the cosmetic surgery that Petitioner requested.

DECISION

Based upon the foregoing findings of fact and conclusions of law, the undersigned hereby determines that Respondent’s decision to deny prior approval for cosmetic surgery should be AFFIRMED.

NOTICE

The North Carolina Health and Human Services, Division of Medical Assistance, will make the Final Decision in this contested case. N.C.G.S. § 150B-36(b), (b1), (b2), and (b3) enumerate the standard of review and procedures the agency must follow in making its Final Decision, and adopting and/or not adopting the Findings of Fact and Decision of the Administrative Law Judge.

Pursuant to N.C.G.S. § 150B-36(a), before the agency makes a Final Decision in this case, it is required to give each party an opportunity to file exceptions to this decision, and to present written arguments to those in the agency who will make the Final Decision. N.C.G.S. § 150B-36(b)(3) requires the agency to serve a copy of its Final Decision on each party, and furnish a copy of its Final Decision to each party’s attorney of record and to the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, N.C. 27699-6714.

This the 4th day of September, 2003.

______

Beecher R. Gray

Administrative Law Judge