Title: Jacobus v. Dept. of PATH

State: vermont

Issuer: Vermont Supreme Court

Document:

Jacobus v. Dept. of PATH (2003-220); 177 Vt. 496; 857 A.2d 785

2004 VT 70

[Filed 29-Jul-2004]
                  
                                 ENTRY ORDER

                                 2004 VT 70

                      SUPREME COURT DOCKET NO. 2003-220

                             JANUARY TERM, 2004

  Christina Jacobus, Lindsey Turgeon   }	APPEALED FROM:
  and  Megan Woods	               }
                                       }
       v.	                       }	Human Services Board
                                       }	
  Department of PATH	               }
                                       }	DOCKET NOS. 17,070 17,490 17,522

             In the above-entitled cause, the Clerk will enter:

       ¶  1.  In these consolidated cases, petitioners Lindsey Turgeon and
  Megan Woods appeal the Secretary of Human Services' (Secretary) denial of
  their request for coverage of interceptive orthodontic treatment under
  Medicaid's Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
  program. (FN1)  Originally, the Human Services Board granted coverage on
  grounds that, although petitioners do not meet the State's listed criteria
  for medically necessary orthodontic treatment, they have at least the same
  medical need for treatment as children whose conditions are on the list. 
  The Secretary rejected certain of the board's factual findings and reversed
  its decision.  Because the Secretary's order violates federal law, we
  reverse.

       ¶  2.  At the time of the proceedings below, petitioners were
  nine-year-old medicaid eligible girls. Megan had persistent pain in her
  teeth, particularly when eating.  Lindsey had chronic pain in her jaw and
  speech difficulties.  The girls' family dentists referred them for
  orthodontic treatment and they saw the same orthodontist, Dr. Fred
  Salvatoriello.  Dr. Salvatoriello diagnosed various multiple malocclusions
  in each girl and recommended interceptive orthodontic treatment in each
  case.   

   
       ¶  3.  The Department of Prevention, Assistance, Transition and Health
  Access (PATH) denied petitioners request for Medicaid coverage on grounds
  that interceptive treatment was not "medically necessary" for either child. 
  PATH regulations provide two means by which treatment can qualify as
  medically necessary.  Under the first method, PATH requires that a child
  have either one major or two minor malocclusions, which are defined
  according to diagnostic criteria established by PATH's dental consultants. 
  Medicaid Manual § M622.4,  5 Code of Vermont Rules 13 170 008-233 (2001).
  (FN2)  In Megan's case, she met the criteria for one minor condition
  (blocked cuspids) but fell just below the criteria for two others (anterior
  open bite and crowding per arch).  In Lindsey's case, none of her four
  diagnosed malocclusions (blocked cuspids, anterior open bite, anterior
  crossbite and crowding) met the listed criteria.  Alternatively, PATH also
  provides for coverage of orthodontic treatment "if otherwise necessary
  under EPSDT found at M100."  Id.   It is undisputed that PATH did not
  review either girl's condition to determine whether treatment was
  "otherwise necessary."
         
       ¶  4.  In consolidated appeals to the board, petitioners argued that
  by limiting interceptive orthodontic coverage to the exact conditions
  described in the listed criteria, without conducting an individualized
  review of each child's medical need, PATH violated its own regulations as
  well as federal statutes and regulations governing the EPSDT program. 
  Petitioners further argued that the State's denial of coverage violated
  their right to equal treatment under the Vermont and federal constitutions. 
  After a de novo fair hearing, the board approved coverage under the
  individualized review prong of the state regulations, holding that each
  child's condition was at least as severe in terms of functional compromise
  as conditions preapproved by the State for coverage.

       ¶  5.  On review pursuant to 3 V.S.A. § 3091(h)(2), the Secretary
  overturned the board's decision.  First, the Secretary reversed without
  explanation the board's findings that each girl's multiple malocclusions,
  considered cumulatively, were at least as severe as any listed conditions.
  Second, the Secretary held that "even assuming for argument's sake that
  they did have such an 'equivalent' condition to those described in our
  criteria," that is not enough.  Instead, the Secretary held that state
  regulations require coverage of orthodontic treatment only where a child
  has a "handicapping malocclusion."  Petitioners timely appealed the
  Secretary's order to this Court pursuant to 3 V.S.A. § 3091(h)(3).

       ¶  6.  Petitioners first challenge the Secretary's rejection of
  board findings thirty-nine and forty-six, which determined that the net
  effect of each child's combined dental impairments was at least as severe
  "in terms of functional compromise" (Lindsey), or "in terms of present
  functioning" (Megan) as the conditions listed by the state.  
   

       ¶  7.  The Secretary may reverse or modify factual findings in a
  board decision only if "the board's findings of fact lack any support in
  the record."  3 V.S.A. § 3091(h)(1)(A) (emphasis added).  This is identical
  to the clearly erroneous standard that this Court applies when reviewing
  the board's findings of fact.  See, e.g.,  In re Potter, 2003 VT 101, ¶
  10,