Case Title: Urban v. Meconi

Citation: 

Docket Number: 439, 2006

State: delaware

Court: Delaware Supreme Court

Date: 2007-08-10T00:00:00Z

Document:
IN THE SUPREME COURT OF THE STATE OF DELAWARE
KANDASE URBAN,
 
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No. 439, 2006
Appellant Below,
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Appellant,
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Court Below: Superior Court
v.
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of the State of Delaware,
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in and for New Castle County
VINCENT P. MECONI,
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C.A. No. 05A-10-002 
in his official capacity as
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Secretary of the Delaware
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Department of Health and
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Social Services,
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Appellee Below, 
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Appellee.
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Submitted: May 23, 2007
Decided: August 10, 2007
Before BERGER, JACOBS and RIDGELY, Justices.
Upon appeal from the Superior Court.  REVERSED and REMANDED.
MaryBeth Musumeci, Esquire, Community Legal Aid Society, Inc., Wilmington,
Delaware, for Appellant.
A. Ann Woolfolk, Esquire, State of Delaware Department of Justice, Wilmington,
Delaware, for Appellee.
BERGER, Justice:
Joint Appendix, A-99.
1
2
In this appeal, we consider whether the Delaware Department of Health and
Social Services (DHSS) properly denied a claimant’s request for surgery under the
Medicaid Early and Periodic Screening Diagnostic and Treatment (EPSDT) program.
DHSS determined that the surgery was not the “least costly, appropriate, available
health service alternative”  because the claimant would benefit from weight loss prior
1
to surgery.  The claimant’s treating physician determined that the surgery was
medically necessary, after giving consideration to her weight.  In addition, the
claimant obtained a second opinion  confirming that surgery was medically necessary.
DHSS’s contrary decision failed to consider the treating physicians’ opinions and was
not supported by substantial evidence.  Accordingly, we reverse.
Factual and Procedural Background
Kandase Urban, who is now almost 20 years old, is suffering pain, rashes, and
other adverse effects from bilateral macromastia.  She receives Medicaid benefits
through Delaware Physicians Care, Inc. (DPCI), the managed care program that
administers the Delaware Medical Assistance Program .  In December 2004, Urban’s
primary care physician referred her to Dr. Lawrence Chang, a plastic surgeon, for
consideration of breast reduction surgery.  Chang noted that Urban was obese (she is
5 feet 2 inches tall and weighed 198 pounds at that time); and that she was suffering
Joint Appendix, A-4.
2
Joint Appendix, A-5.
3
Joint Appendix, A-8.
4
3
from chest and back pain, rashes, shoulder grooving and depression.  In a letter
submitted to DPCI on December 22, 2004, Chang concluded:
My overall impression is symptomatic bilateral macromastia with
associated obesity.  She would benefit from a reduction
mammoplasty, but her weight should ideally come down to the
160 range if possible, or show no increase in size.  I feel the better
option would be to refine with diet and exercising.  However, the
exercising may be difficult due to enlarged breasts.  The mother
states that they will work on the diet program, but we will submit
this for preauthorization for reduction mammoplasty, and see her
back within 6-8 weeks time to see what her weight status is.2
In January 2005, DPCI denied the request, stating that Urban is obese and that
“[w]eight reduction would likely be in her best health interests as well as instrumental
in reducing breast size.”   Urban requested an appeal with DPCI and a “fair hearing”
3
with the Department of Health and Social Services Division of Medicaid and Medical
Assistance.  In February 2005, DPCI denied Urban’s appeal.  The denial letter
repeated DPCI’s earlier explanation about weight reduction being in Urban’s best
interests.  In addition, the denial letter stated that the requested surgery does not meet
Delaware’s definition of medical necessity because surgery is not “the most
appropriate care or service that can be safely and effectively provided” ; and because
4
Joint Appendix, A-15.
5
4
it is not the treatment of choice or common medical practice.
In May 2005, after Urban had succeeded in losing approximately 15 pounds,
she had a second appointment with Chang.  He noted that, despite losing weight,
Urban’s breast size and symptoms remained the same.  By letter dated May 13, 2005,
Chang again requested authorization for breast reduction surgery.  In his May letter,
Chang stated:
My initial recommendation was for her to reduce some weight,
which she has successfully done and come down at least 15
pounds.
*
*
*
She has done very well as far as improving her weight.  I feel that
having the 15 pound weight loss should allow a better result from
a bilateral reduction mammoplasty, and I feel that she is at a
reasonable weight at this present time to proceed with surgery.
My recommendation is to do a resection ....5
Two weeks after seeing Chang, Urban sought a second opinion from Dr.
Benjamin Cooper, also a plastic surgeon.  Cooper agreed with Chang’s diagnosis of
symptomatic macromastia, and he also agreed that Urban would benefit from breast
reduction surgery.  Cooper submitted his own request for authorization, although it
is not clear from this record whether DPCI received or responded to it.
DHSS considered Urban’s appeal at a hearing  on August 15, 2005.  Dr. Phillip
Joint Appendix, A-32.
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5
Waldor, DPCI’s medical director, testified that Urban does not qualify under the
criteria DPCI uses because she is obese.  Waldor determined that Urban had a Body
Mass Index (BMI) of 36 at the time Chang first requested authorization. He testified
that DPCI would approve the surgery if Urban reduced her weight to 160 pounds,
which would bring her BMI below 30.  To assist in that effort,  DPCI authorized
Urban to have multiple visits to a nutrition clinic.  Shortly before the hearing, Waldor
testified that he tried to find out Urban’s “current weight status to determine whether
we could have possibly approved this at this point ....”  He was unsuccessful, but he
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reaffirmed to the hearing officer that DPCI would approve surgery if Urban’s weight
came down to 160 pounds.
Dr. Benjamin Cooper testified that surgery was necessary to alleviate Urban’s
back pain and rashes.  He explained that a study sponsored by the American Society
of Plastic Surgery supported his opinion.  Cooper stated that women with macromastia
rarely lose significant amounts of weight prior to surgery, and that he was not sure
whether there would be any benefit if Urban lost another 10 - 15 pounds  (other than
the general health benefit of being closer to an optimal weight).  On the other hand,
Cooper could not say that delaying the surgery would cause any physical harm to
Urban.
Joint Appendix, A-99-100.
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Urban’s mother, Lisa Barben,  testified about how Urban’s condition limited
her daily activities.  She said that Urban does not walk straight and cannot engage in
any physical activities for long periods of time without chest and back pain.  Urban
lost her part-time job at a fast food restaurant because she could not meet the physical
demands of the work.   On cross-examination,  Barben testified that she did not think
Urban’s macromastia could be resolved through weight loss.  She based that opinion
on the fact that,  despite having lost about 15 pounds during the period from
December 2004 - May 2005, Urban’s breasts had increased in size.   
From this record, DHSS concluded: 
Claimant’s general health is important enough to warrant
additional weight loss efforts, rather than proceeding immediately
with breast reduction surgery based on a belief that her breast size
will never decrease no matter how much weight she loses.
*
*
*
Because allowing the Claimant to continue her weight loss efforts
will not negatively impact her from a physical perspective and
will positively impact her from a surgical perspective if she does
qualify for the surgery, approving her breast reduction surgery at
this point is not the least costly, appropriate, available health
service alternative and does not represent an effective and
appropriate use of program funds.7
The Superior Court affirmed.  It found that DHSS’s decision was supported by
the record because all of the doctors agreed that Urban would benefit from weight loss
Title XIX of the Social Security Act, 42 U.S.C.§§1396-1396s.
8
42 U.S.C. §§ 1396a(a)10(A), 1396d(4)(B).  
9
42 U.S.C. §1396d(5)(5).
10
31 Del.C. § 520; Stoltz Management v. Consumer Affairs Board, 616 A.2d 1205 (Del.
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1992).
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before surgery, and authorization for surgery was “only postponed.”  This appeal
followed.
Discussion
The Medicaid Act  is a federal-state program designed to provide medical care
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for those without sufficient financial resources to pay for that care themselves.  As a
participating state, Delaware must comply with federal statutory and regulatory
requirements.  Under the Act, states are required to provide “early and periodic
screening, diagnostic, and treatment services” (EPSDT) for Medicaid-eligible
individuals under 21 years old.   Those services include:  “necessary health care,
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diagnostic services, treatment, and other measures ... to correct or ameliorate defects
and physical and mental illnesses and conditions ... whether or not such services are
covered under the State plan.”10
This Court, like the Superior Court, reviews the DHSS fair hearing decision  to
determine whether it is supported by substantial evidence and free of legal error.11
Urban argues that DHSS erred in numerous respects, including: 1) applying the wrong
Although we do not reach this issue, we consider it noteworthy that DHSS, itself, took the
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position that the relevant sections of the Delaware Social Services Manual are inconsistent and
“improper.” (Appellee’s Answering Brief at 17-18).  In light of that admission, we assume DHSS
is reviewing the Manual and making appropriate changes.
CDR 16 5000.5100.
13
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definition of medical necessity; 2) improperly allocating the burden of proof ; 3)
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failing to consider all of the evidence; and 4) failing to give deference to the opinions
of her treating physicians.  We do not reach all of Urban’s claims because we
conclude that Urban’s last two arguments have merit, and that the record as a whole,
when properly considered,  mandates approval of Urban’s surgery.
The Delaware Social Services Manual (DSSM)  sets forth the practice and
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procedures governing fair hearings for public assistance programs, including
Medicaid.  DSSM §5406.1 provides that the hearing officer must follow applicable
federal and state court precedent, in that order.  Thus, we look to the United States
Court of Appeals for the Third Circuit for its articulation of the “substantial evidence”
standard of review as well as the deference to be accorded to a treating physician’s
opinion.  In deciding whether claimants are entitled to social security disability
benefits, that court explained:
This Court has defined substantial evidence as “such relevant
evidence as a reasoning mind might accept as adequate to support
a conclusion ....” This oft-cited language is not, however, a
talismanic or self-executing formula for adjudication; rather, our
decisions make clear that determination of the existence vel non
Brewster v. Heckler, 786 F.2d 581, 584 (3  Cir. 1986)(Citations omitted; emphasis in
14
rd
original.).
Wallace v. Secretary of Health and Human Services, 722 F.2d 1150,1155 (3  Cir. 1983).
15
rd
Podedworny v. Harris, 745 F.2d 210, 217 (3  Cir. 1984).
16
rd
Id. at 218.
17
Van Horn v. Schweiker, 717 F.2d 871, 874 (3  Cir. 1983).
18
rd
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of substantial evidence is not merely a quantitative exercise.  A
single piece of evidence will not satisfy the substantiality test if
the Secretary ignores, or fails to resolve, a conflict created by
countervailing evidence.  Nor is evidence substantial if it is
overwhelmed by other evidence - particularly certain types of
evidence (e.g., that offered by treating physicians) - or if it really
constitutes not evidence but mere conclusion.14
The federal court requires that the administrative decision-maker (here, DHSS) give
“substantial weight”  to the opinions of treating physicians;  that DHSS generally
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should give less probative weight to the opinion of a physician who has never
examined the patient;  that DHSS should explain its reasons for rejecting any expert
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evidence;  and that DHSS should not substitute its expertise for the competent
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medical evidence.18
The record establishes that DHSS failed to adhere to these standards in
affirming the denial of Urban’s surgery.  Waldor was the only witness for DPCI.  He
never examined Urban, and he never explained the basis for DPCI’s requirement that
a claimant not be obese in order to qualify for reduction mammoplasty.  In fact,
DHSS complains that Cooper is not Urban’s treating physician, and that Chang’s second
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letter should not be considered because it post-dates the January 2005 denial of the request for
surgery.  Cooper was consulted for a second opinion, and he testified that he examined Urban,
recommended surgery, and submitted a request for authorization.  Presumably, if that request had
been approved, Cooper would have become Urban’s treating physician.  Whether he qualified for
the title “treating physician” before that time is not particularly important on this record.  As a
surgeon who examined Urban, his medical opinion deserved more weight than Waldor’s.
On the second issue, we find it difficult to understand DHSS’s position.  Chang’s first letter
explained that he was going to follow-up with his patient to review her weight loss and decide
whether she was ready for surgery.  The second letter provided that follow-up.  Surely DHSS is not
suggesting that the long and expensive application/appeal process must be started again in order to
consider a medical update from Urban’s treating physician.  As it is, this process has taken more
than two years, during which time Urban has had to cope with the pain and debilitating effects of
her medical condition, without relief.  Moreover, and to his credit, Waldor testified that he was
prepared to approve the surgery at the time of the hearing if Urban lost the weight he deemed
necessary.  Thus, Waldor tacitly acknowledged that the fair hearing decision should be based on
Urban’s then current medical condition.  We agree.   
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Waldor  agreed that the surgery is medically necessary –   he testified that he would
approve the surgery if Urban’s weight came down to 160 pounds.
Urban’s treating physicians  both testified that surgery was medically
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necessary at her then current weight of approximately 182 pounds.  There was no
evidence disputing the necessity of the surgery, or the fact that reduction
mammoplasty is the standard of care for Urban’s medical condition.  The only issue,
as revealed at the fair hearing, was whether Urban would benefit from additional
weight loss before surgery. 
Not surprisingly, all the doctors agreed that she would.  Moreover, Cooper
acknowledged that, if Urban were able to bring her weight down to 160 pounds, that
Joint Appendix, A - 55.
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weight loss possibly could have “some impact” on her breast size.  But Urban’s
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doctors considered her weight, and the amount she had been able to lose, and
prescribed surgery as the medically necessary, appropriate treatment.  Cooper
explained that women suffering from symptomatic macromastia usually are
overweight, and that weight loss generally does not eliminate the need for breast
reduction surgery.  In Urban’s case, the evidence was that she lost 15 pounds without
any reduction in breast size.  
DHSS concluded that Urban should try to lose more weight before, and perhaps
in lieu of, surgery.  DHSS acknowledged that Urban’s weight loss thus far had not
reduced her breast size, but it noted that weight loss would be good for Urban and
that Cooper “opined” that additional weight loss might result in breast reduction.
DHSS never even mentioned the fact that both Chang and Cooper opined that surgery,
without additional weight loss, was medically necessary.  Thus, it appears that DHSS
not only failed to give any deference to the competent medical evidence, but also it
failed to consider that evidence at all. 
Having carefully reviewed the record, we conclude that DHSS’s decision was
not supported by substantial evidence.  There was no evidence that Urban’s condition
could be treated by weight loss alone, and all of the medical evidence confirmed that
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surgery was necessary.  Accordingly, authorization for Urban to undergo reduction
mammoplasty should have been granted.
Conclusion
Based on the foregoing, the decision of the Superior Court is reversed and this
matter is remanded for the Superior Court to enter an order in accordance with this
decision.