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STATE OF NORTH CAROLINA IN THE OFFICE OF
ADMINISTRATIVE HEARINGS
COUNTY OF ROWAN 06 DHR 1162
RHONDA BUMGARNER, )
Petitioner; )
) DECISION
vs. )
)
NORTH CAROLINA DEPARTMENT OF )
HEALTH AND HUMAN SERVICES, )
DIVISION OF MEDICAL ASSISTANCE, )
Respondent. )
A Petition for a contested case hearing was filed in the North Carolina Office of Administrative Hearings on June 28, 2006. Petitioner contested Respondent’s decision to deny Petitioner’s prior approval request for a surgical panniculectomy (removal of abdominal skin).
A Notice of Contested Case and Assignment, Order for Prehearing Statements and Scheduling Order was filed on July 3, 2006. Respondent filed a Prehearing Statement.
On August 21, 2006, Respondent filed a Motion for Summary Judgment alleging there were no genuine issues as to material fact and that Respondent was entitled to judgment as a matter of law because Petitioner did not meet the medical necessity criteria for this Medicaid covered surgery. Petitioner did not file a response to such motion.
Petitioner appears pro se. Respondent is represented by Brenda Eaddy, Assistant Attorney General, North Carolina Department of Justice.
Based upon a review of the documents of record and Respondent’s Motion with accompanying affidavit, the undersigned finds that Summary Judgment in favor of Respondent should be ALLOWED. The following constitute:
UNDISPUTED FACTS
1. Respondent (DMA) is responsible for administering and managing the State Medicaid plan and program. Pursuant to N.C. Gen. Stat. §108A-54, Respondent is authorized to adopt rules and regulations for program operation.
2. Petitioner filed a petition in the Office of Administrative Hearings on June 28, 2006, to contest the decision of Respondent to deny Petitioner’s prior approval request for a surgical panniculectomy.
3. The criteria for Medicaid to authorize panniculectomy surgery are found in Medicaid Clinical Coverage Policy No. 1A-10. Section 3.0 of this clinical coverage policy states that a panniculectomy is covered if the recipient is at least 19 years old; and has a BMI (body mass index) of 40 or above, or has had prior gastric bypass surgery or gastric stapling surgery.
4. Maria Welch is employed by Respondent. Her job duties include reviewing medical records of Medicaid recipients in order to determine whether DMA will cover requested surgical procedures.
5. Information submitted to Maria Welch from Farrington Family Medical Center, one of Petitioner’s medical providers, show that Petitioner is 5 feet, 6 inches tall and weighed 202.7 pounds on May 1, 2006. The resulting BMI index is 33.7.
6. The medical documentation submitted to Maria Welch does not establish that Petitioner has had either a prior gastric bypass surgery or gastric stapling surgery.
7. Petitioner’s BMI index is not at 40 or above and Petitioner’s medical evidence does not show that she has had prior gastric surgery. Petitioner does not meet the medical coverage criteria for a Medicaid covered surgical panniculectomy.
Based upon the foregoing findings of fact, the undersigned makes the following
CONCLUSIONS OF LAW
1. The NC Office of Administrative Hearings has jurisdiction over the parties and subject matter of this contested case pursuant to N.C. Gen. Stat. §150B-23 et seq., and there is no question as to misjoinder or nonjoinder.
2. Medicaid Clinical Coverage Policy No. 1A-10 sets out the criteria Respondent must follow in order to approve a surgical panniculectomy. Section 3.0 of this clinical coverage policy states that a panniculectomy is covered if the recipient is at least 19 years old; and has a BMI of 40 or above, or has had prior gastric bypass surgery or gastric stapling surgery.
3. The medical documentation submitted for to Respondent for prior approval of a surgical panniculectomy does not meet the criteria set out in Clinical Policy 1A-10.
DECISION
NOW, THEREFORE, based on the foregoing Findings of Fact and Conclusions of Law, the Undersigned determines that Respondent’s decision not to approve the requested surgical panniculectomy was pursuant to its clinical coverage policy and was appropriate.
NOTICE
The agency making the final decision in this contested case 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 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, giving due regard to the opportunity of the Administrative Law Judge to evaluate the credibility of witnesses. For each finding of fact not adopted by the agency, the agency shall set forth separately and in detail the reasons for not adopting the finding of fact and the evidence in the record relied upon by the agency. Every finding of fact not specifically rejected as required by Chapter 150B shall be deemed accepted for purposes of judicial review. 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 establishing that the new finding of fact is supported by a preponderance of the 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. This agency is required by N.C. Gen. Stat. §150B-36(b) to serve a copy of the final decision on all parties and to furnish a copy to the parties’ attorneys of record and to the Office of Administrative Hearings.
IT IS SO ORDERED.
This is the 14th day of September, 2006.
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Beecher R. Gray
Administrative Law Judge