02/19/08

MASSACHUSETTS:  Court: MassHealth Must Consider Payment for HIV-Related Surgery

On Tuesday, the Massachusetts Appeals Court ordered the state's Medicaid provider to reconsider a claim it rejected for HIV-related surgery. The ruling overturns a lower court decision that affirmed MassHealth's refusal to pay for the removal of a lump of fat from the neck of Ashley Shaw, who was born with HIV, since the surgery was performed without prior approval.

The Division of Medical Assistance (DMA), which oversees MassHealth, rejected coverage for the surgery shortly before the operation in May 2004, when Ashley was then 15. Doctors said removing the lump of fat, sometimes referred to as a "buffalo hump," was medically necessary because it was large for a 115-pound girl, disfiguring Ashley to the point it caused abnormal posture, difficulty swallowing, neck and back pain, headaches, and made her unable to sleep without medication.

Despite the denial of coverage, Ashley's mother, Elizabeth Shaw, agreed with Ashley's doctors that the surgery should go ahead. Elizabeth also appealed the decision to MassHealth.

At a later hearing, a MassHealth official said the operation did not "meet medical necessity criteria," and was not a covered procedure. Furthermore, he said the claim "would have to be denied because it's a retroactive request," according to the Appeals Court ruling.

"We reject DMA's view that the review of Ashley's claim may be terminated because the procedure had been performed without authorization," Appeals Court Judge Elspeth Cypher wrote. "To treat prior authorization as overriding all other considerations is not consistent with the regulation's purpose."

The court said Ashley's mother had no choice but to consent to the surgery, for which she paid a surgeon's fee of $2,000 out-of-pocket, since there was "no timely and reasonable alternative available" after the initial denial. The court said the initial request was made before the operation, and as it was still pending it "cannot be considered a 'retroactive request.'" The Appeals Court ordered MassHealth to review the claim based on its medical merits.

Source: Associated Press:: Steve LeBlanc; Courtesy of the CDC National Center for HIV, STD, and TB Prevention