Opinion ID: 2630566
Heading Depth: 3
Heading Rank: 2

Heading: The Agency's Denial of Coverage for Mr. Garner's Routine Dental Care May Have Been Inconsistent with Its Own Regulations.

Text: In his appeal to the superior court, Garner argued that the state failed to follow its own regulations in denying his claim. [21] The state's Medicaid regulations contain a provision allowing the agency to make exceptions under the appropriate circumstances. Thus, 7 AAC 43.080(a) provides: The need for medical care is not subject to inflexible determination, which can be described completely in policy or regulations. Professional judgment must be exercised in each case and exceptions granted in those instances where unusual circumstances exist. Where undue hardship may result to an individual if medical care services are denied by strict application of regulations, exceptions to policy may be made when considered appropriate by the division. In his decision, Hearing Officer James M. Leonard stated that [n]one of the federal or state Medicaid regulations I reviewed, which pertained to covered and excluded Medicaid services, referenced exceptions for any individualseven those who were severely disabled. When Garner pursued his administrative appeal, Bob Labbe, Director of the Division of Medical Assistance, concurred with the hearing officer's decision to deny Garner's request for routine dental care. At no time did Hearing Officer Leonard or Director Labbe mention section 43.080 of the regulations or inquire into its applicability. In his brief to the superior court, Garner argued that if the agency [had] taken the proper action and made a determination under this regulation it would necessarily have determined that routine dental care is a necessity for Mr. Garner. However, as Garner further noted, contrary to its own regulations, it chose to strictly apply some of its regulations and to ignore others. In reply, the state contended that while 7 AAC 43.080 provides for exceptions based on unusual circumstances or undue hardship[,] ... Mr. Garner's routine dental care does not qualify for this exception. The state offered no support for its position, and we see none in the record. While there are numerous statements from Garner's doctors and caretakers indicating that Garner would suffer undue hardship should he be denied these otherwise routine dental services, the state has offered no evidence to the contrary and the agency has made no factual findings on which such a conclusion could be based. While the decision whether denial of Medicaid coverage for the dental care Garner received constitutes an undue hardship is committed to the discretion of the agency, we believe the agency abused that discretion by failing to even consider whether the exception applied. We have held it to be legal error for an agency to fail to apply exceptions found in its own regulations or, at the very least, to inquire into their applicability. [22] Because the agency failed to inquire into the applicability of subsection 43.080(a), we remand to the superior court with instructions to remand to the agency for further findings on whether the agency's denial of coverage for Garner's otherwise routine dental care would result in an undue hardship for him and, if so, whether the requested services should be covered under this exception.