Opinion ID: 616458
Heading Depth: 2
Heading Rank: 1

Heading: Available, accessible, and adequate services

Text: A Medicare Advantage organization must make its covered services available and accessible. 42 C.F.R. § 422.112(a). If the organization's in-network specialty care is unavailable or inadequate to meet the enrollee's medical needs, it must arrange out-of-network care. 42 C.F.R. § 422.112(a)(3). The Department of Health and Human Services (HHS) stated during its rulemaking procedures that this duty is triggered when, for example, the plan includes no specialist qualified to treat an enrollee's rare condition. 65 Fed.Reg. 40,170, 40,199 (June 29, 2000). Conahan contends that Kaiser's refusal to perform liver surgery rendered its services unavailable, inaccessible, and inadequate, and therefore Kaiser must cover the out-of-plan surgery. The MAC disagreed, concluding that Kaiser denied the enrollee a referral to an out-of-network provider; it did not deny her medical care that was reasonably believed to be within the standard of appropriate medical care, as determined by multiple physicians[.] We agree with the district court that substantial evidence supports the MAC's conclusion. The record contains abundant evidence that Kaiser thoroughly considered performing surgery, but determined that it would be too dangerous and ineffective. Dr. Matayoshi testified to the ALJ that Kaiser's multidisciplinary Tumor Board concluded that the surgery would require removal of up to 80% of Glaser's liver, which would likely result in Glaser not having enough liver remaining to survive. The only physician to reach a different conclusion than the Tumor Board was Dr. Lin-Hurtubise, who performed the surgery. This disagreement does not significantly undermine the conclusion of approximately thirty physicians on the Tumor Board. See Am. Textile Mfrs. Inst., Inc. v. Donovan, 452 U.S. 490, 523, 101 S.Ct. 2478, 69 L.Ed.2d 185 (1981) ([T]he possibility of drawing two inconsistent conclusions from the evidence does not prevent an administrative agency's finding from being supported by substantial evidence.) (internal quotation marks and citation omitted). Moreover, the record contains substantial evidence that Kaiser developed a comprehensive plan to shrink the tumor with chemoembolization. Dr. Matayoshi testified that if the tumor shrank, Kaiser would reconsider whether to perform surgery. Dr. Matayoshi described Glaser's surgical oncologist, Dr. Takamori, as our resource for all of our liver tumors and very well qualified to treat Glaser. Conahan claims that the MAC should not have considered this evidence because Kaiser had not informed Glaser of the chemoembolization plan. However, the administrative record contradicts this claim. Dr. Matayoshi testified that he mentioned chemoembolization to Glaser in a telephone call before she underwent surgery. Moreover, Dr. Takamori planned to discuss further the treatment plan with Glaser, but Glaser failed to appear for her two scheduled appointments. The district court correctly rejected the implicit contention that [Glaser] can refuse appointments with in-network providers and, at the same time, argue that alternative options were not made available to her. Conahan contends that the MAC erred by relying on Dr. Matayoshi's testimony, which she claims the ALJ discredited. As support for her position, Conahan cites Pogue v. United States Dep't of Labor, 940 F.2d 1287 (9th Cir.1991), in which we held that [s]pecial deference is to be given the ALJ's credibility judgments. Id. at 1289 (citation and internal quotation marks omitted). In Pogue, we reviewed the Secretary of Labor's dismissal of an employment complaint against the Navy. The ALJ in that case stated that testimony from the plaintiff's supervisor was not credible, but the Secretary of Labor nonetheless relied on that testimony. Id. at 1290-91. In contrast, the ALJ here did not find that Dr. Matayoshi's testimony lacked credibility. In fact, the ALJ's opinion does not explicitly mention Dr. Matayoshi's hearing testimony, and Conahan has not cited any authority that would require us to interpret the ALJ's silence on that testimony as a finding that the testimony lacks credibility. Furthermore, the ALJ wrote that he accepts the medical opinions of all physicians' [sic] involved as opinions based upon their best medical assessment of the Appellant's condition at the time. Because the ALJ did not find that Dr. Matayoshi's testimony lacked credibility, the MAC was free to consider the evidence. In sum, we conclude that substantial evidence in the administrative record supports the MAC's determination that Kaiser's services were available, accessible, and adequate, and therefore that 42 C.F.R. § 422.112(a)(3) does not require Kaiser to pay for the surgery.