Court Opinion

ID: 4695015
Source: CourtListenerOpinion
Date Created: 2021-06-11 20:20:56.125809+00
Date Added: 2024-06-11T08:05:32.884177
License: Public Domain

IN THE SUPREME COURT OF APPEALS OF WEST VIRGINIA

                            January 2021 Term                       FILED
                         _____________________                   June 11, 2021
                                                                    released at 3:00 p.m.
                                                                EDYTHE NASH GAISER, CLERK
                                                                SUPREME COURT OF APPEALS
                              No. 20-0308                            OF WEST VIRGINIA
                         _____________________

 AMEDISYS WEST VIRGINIA, LLC dba AMEDISYS HOME HEALTH OF WEST
VIRGINIA, ST. MARYS MEDICAL CENTER HOME HEALTH SERVICES, LLC, and
               LHC GROUP, INC., Petitioners Below, Petitioners

                                    v.

   PERSONAL TOUCH HOME CARE OF W.VA., INC. et al., and THE WEST
   VIRGINIA HEALTH CARE AUTHORITY, Respondents Below, Respondents

     ___________________________________________________________

              Appeal from the Circuit Court of Kanawha County
                   The Honorable Tod J. Kaufman, Judge
                        Civil Action No. 19-AA-145

                             AFFIRMED
      _________________________________________________________

                                 AND
                         _____________________

                              No. 20-0401
                         _____________________

             PRESTON MEMORIAL HOMECARE, LLC, et al.,
                    Petitioners, Below, Petitioners

                                    v.

 UNITED HOSPITAL CENTER, INC., and THE WEST VIRGINIA HEALTH CARE
               AUTHORITY, Respondents Below, Respondents
     ___________________________________________________________

              Appeal from the Circuit Court of Kanawha County
                     The Honorable Carrie L. Webster, Judge
                          Civil Action No. 18-AA-228

                               AFFIRMED
        _________________________________________________________

                           Submitted: April 13, 2021
                             Filed: June 11, 2021

Robert L. Coffield, Esq.                      Thomas G. Casto, Esq.
Caleb P. Knight, Esq.                         Anna G. Casto, Esq.
Flaherty Sensabaugh Bonasso PLLC              Lewis Glasser PLLC
Charleston, West Virginia                     Charleston, West Virginia
Counsel for Petitioners                       Counsel for Respondent Personal
                                              Touch Home Care of W.Va., Inc.

                                              James W. Thomas, Esq.
                                              Neil C. Brown, Esq.
                                              Jackson Kelly, PLLC
                                              Charleston, West Virginia
                                              Counsel for Respondent United
                                              Hospital Center, Inc.

                                              Patrick Morrisey, Esq.
                                              Attorney General
                                              B. Allen Campbell, Esq.
                                              Senior Assistant Attorney General
                                              Charleston, West Virginia
                                              Counsel for Respondents West
                                              Virginia Health Care Authority and
                                              Department of Health and Human
                                              Resources

JUSTICE WOOTON delivered the Opinion of the Court.
                             SYLLABUS BY THE COURT

     1.           “‘“‘Upon judicial review of a contested case under the West Virginia

Administrative Procedure Act, Chapter 29A, Article 5, Section 4(g), the circuit court may

affirm the order or decision of the agency or remand the case for further proceedings. The

circuit court shall reverse, vacate or modify the order or decision of the agency if the

substantial rights of the petitioner or petitioners have been prejudiced because the

administrative findings, inferences, conclusions, decisions or order are: ‘(1) In violation of

constitutional or statutory provisions; or (2) In excess of the statutory authority or

jurisdiction of the agency; or (3) Made upon unlawful procedures; or (4) Affected by other

error of law, or (5) Clearly wrong in view of the reliable, probative and substantial evidence

on the whole record; or (6) Arbitrary or capricious or characterized by abuse of discretion

or clearly unwarranted exercise of discretion.’ Syllabus point 2, Shepherdstown Volunteer

Fire Department v. West Virginia Human Rights Commission, 172 W.Va. 627, 309 S.E.2d

342 (1983).” Syllabus, Berlow v. West Virginia Board of Medicine, 193 W.Va. 666, 458

S.E.2d 469 (1995).’ Syl. Pt. 1, Modi v. West Virginia Bd. of Medicine, 195 W.Va. 230, 465

S.E.2d 230 (1995).” Syl. Pt. 1, W. Va. Med. Imaging & Radiation Therapy Tech. Bd. of

Exam’rs v. Harrison, 227 W. Va. 438, 711 S.E.2d 260 (2011).

       2.       “‘Judicial review of an agency’s legislative rule and the construction of a

statute that it administers involves two separate but interrelated questions, only the second

of which furnishes an occasion for deference. In deciding whether an administrative

                                              i
agency’s position should be sustained, a reviewing court applies the standards set out by

the United States Supreme Court in Chevron U.S.A., Inc. v. Natural Resources Defense

Council, Inc., 467 U.S. 837, 104 S. Ct. 2778, 81 L. Ed.2d 694 (1984). The court first must

ask whether the Legislature has directly spoken to the precise question at issue. If the

intention of the Legislature is clear, that is the end of the matter, and the agency’s position

only can be upheld if it conforms to the Legislature’s intent. No deference is due the

agency’s interpretation at this stage.’ Syl. Pt. 3, Appalachian Power Co. v. State Tax Dep't

of W. Virginia, 195 W. Va. 573, 466 S.E.2d 424 (1995).” Syl. Pt. 5, Murray Energy Corp.

v. Steager, 241 W. Va. 629, 827 S.E.2d 417 (2019).

      3.       “‘If legislative intent is not clear, a reviewing court may not simply impose

its own construction of the statute in reviewing a legislative rule. Rather, if the statute is

silent or ambiguous with respect to the specific issue, the question for the court is whether

the agency’s answer is based on a permissible construction of the statute. A valid legislative

rule is entitled to substantial deference by the reviewing court. As a properly promulgated

legislative rule, the rule can be ignored only if the agency has exceeded its constitutional

or statutory authority or is arbitrary or capricious. W. Va. Code, 29A–4–2 (1982).’ Syl. Pt.

4, Appalachian Power Co. v. State Tax Dep’t of W. Va., 195 W. Va. 573, 466 S.E.2d 424

(1995).” Syl. Pt. 6, Murray Energy Corp. v. Steager, 241 W. Va. 629, 827 S.E.2d 417

(2019).

                                              ii
       4.        “‘Interpreting a statute or an administrative rule or regulation presents a

purely legal question subject to de novo review.’ Syl. Pt. 1, Appalachian Power Co. v. State

Tax Dep’t of W. Va., 195 W. Va. 573, 466 S.E.2d 424 (1995).” Syl. Pt. 2, Steager v. Consol.

Energy, Inc., 242 W. Va. 209, 832 S.E.2d 135 (2019).

       5.          Where the State Health Plan Home Health Services Standards were

promulgated by the West Virginia Health Care Authority (formerly the West Virginia

Health Care Cost Review Authority) pursuant to a legislative grant of authority, West

Virginia Code §§ 16-2D-1 to -20 (2016 & Supp. 2020), authorized by the Governor, and

formally adopted and given full force and effect by the Legislature, see id. § 16-2D-6(g),

the longstanding, consistent interpretation of those Standards by the West Virginia Health

Care Authority, being neither arbitrary nor capricious, is entitled to judicial deference

pursuant to Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc., 467 U.S. 837

(1984).

                                            iii
WOOTON, J.:

              In these consolidated cases we are called upon to examine the State Health

Plan Home Health Services Standards (“the Standards”), which were promulgated by

respondent West Virginia Health Care Cost Review Authority (“HCCRA”), now the West

Virginia Health Care Authority (“the Authority”), as part of its duties and responsibilities

pursuant to West Virginia Code §§ 16-2D-1 to -20 (2016 & Supp. 2020). The Standards

were approved by the Governor on November 13, 1996. The Standards govern the

Authority’s consideration of applications from individuals and entities seeking to provide

home health care services in a particular county, and include, inter alia, a methodology for

determining whether there is an unmet need for such services in the county. If the

Authority determines that an applicant has demonstrated the existence of unmet need and

has otherwise satisfied all other requirements imposed by the Standards, the agency issues

a Certificate of Need (“CON”) allowing the applicant to offer services in the county.

             Petitioners Amedisys West Virginia, L.L.C. dba Amedisys Home Health of

West Virginia, St. Marys Medical Center Home Health Services, LLC, and LHC Group,

Inc. (“the Amedisys petitioners”) and petitioners Preston Memorial Homecare, LLC and

Tender Loving Care Health Care Services of West Virginia, LLC dba Amedisys Home

Health of West Virginia (“the Preston Memorial petitioners”) (referred to collectively as

“petitioners”) contend that unmet need cannot be established unless the evidence shows

that at least 229 individuals in the county in question are in need of home health care

services. Respondents Personal Touch Home Care of W. Va., Inc. (“Personal Touch”),

                                             1
United Hospital Center, Inc. (“United”), and The West Virginia Health Care Authority

(“the Authority”) (referred to collectively as “respondents”) counter that in an unbroken

line of precedents dating back at least to 2002, the Authority’s position has been that any

number of individuals in need of the services – whether it’s 1 or 100 or 1,000 – can be

deemed sufficient to establish unmet need in the county. According to respondents, the

229 figure is an average county usage figure that comes into play only where another home

health care provider has begun offering services in the county during the preceding 12-

month period; in such case, the Standards require the new applicant to demonstrate a need

at or beyond the 229 average usage figure, a requirement intended to give the recently

established provider sufficient time to develop and grow its business before having to

compete with a newcomer.

              With this background in mind, we turn to the factual and procedural posture

in these consolidated cases and then examine the single, dispositive issue presented in both.

After review, and for the reasons explained herein, the decisions of the circuit court in No.

20-0308 and No. 20-0401 are affirmed.

                          I. Facts and Procedural Background

No. 20-0308

              In the first case, the Amedisys petitioners contend that a CON issued by the

Authority to respondent Personal Touch was improper in that Personal Touch failed to

                                             2
demonstrate the requisite unmet need for additional home health services in Cabell and

Wayne Counties.

             On August 10, 2018, Personal Touch filed its application for a CON allowing

it to expand its existing home health care services into Cabell and Wayne Counties. See

id. § 16-2D-8(b)(23). In this regard, “[a] certificate of need may only be issued if the

proposed health service is: (1) Found to be needed; and (2) Consistent with the state health

plan, unless there are emergency circumstances that pose a threat to public health.” See id.

§ 16-2D-12(a). According to the calculations contained in the application filed by Personal

Touch, which followed the methodology contained in Section V(C)(1) – (3) of the

Standards, 1 the unmet need for home health care services was 29 individuals in Cabell

County and 55 individuals in Wayne County.

             On August 14, 2018, the application was deemed complete, see id. § 16-2D-

13(c), and two days later, on August 16, 2018, the Authority issued a Notice of Review.

       1
         The methodology actually contains four calculations: the first compares the county
and state home health utilization rates; the second determines the number of potential home
health care recipients needed to reach the state rate; the third determines the actual number
of home health care recipients below the state rate; and the fourth, which comes into play
only where there are agencies in the county which received CON approval within the
previous 12 months, applies an adjustment factor to determine unmet need. See text infra
for a detailed discussion of these calculations. See Standards, V(C)(1) – (4), “Determining
Unmet Need for Home Health Services.” Because none of the existing home health
services providers in either Cabell County or Wayne County had received a CON during
the 12-month period preceding Personal Touch’s application, see text infra, the fourth
calculation was not applicable.
                                             3
See id. § 16-2D-13(d).       Thereafter, the Amedisys petitioners sought recognition as

“affected persons,” statutorily defined in relevant part as “health care facilit[ies] located

within this state which provide services similar to the services of the facility under review

and which will be significantly affected by the proposed project.” See id. § 16-2D-2(1)(E).

Of particular relevance to this case, it is important to note that all existing home health care

providers in Cabell and Wayne County, 2 including the Amedisys petitioners, had been

providing such services for more than 12 months preceding Personal Touch’s application

for a CON.

                On December 12, 2018, a public hearing was held to determine whether the

application of Personal Touch for a CON, which would allow it to expand its services into

the counties in question, should be granted or denied by the Authority. To establish their

case as affected parties, the Amedisys petitioners called Charles G. Gibbs, a health care

consultant who was recognized as an expert in the field, to testify on their behalf. Mr.

Gibbs took issue with the Personal Touch application in three respects. First, he contended

that Personal Touch had based its unmet need calculations on 3-year-old data from fiscal

year 2015, rather than on updated data from fiscal year 2017 which had been made publicly

available on July 31, 2018, 10 days before Personal Touch filed its application. 3 In this

       2
         The record discloses that during the relevant time period, there were ten home
health care providers in Cabell County and eleven in Wayne County.
       3
           See text infra.
                                               4
regard, Mr. Gibbs noted that the form used for applying for a CON specifies that “readily

available data” be used and argued that the updated data was readily available in time to

have been incorporated into the application. Second, Mr. Gibbs argued that Personal

Touch had applied the wrong methodology for determining unmet needs in Cabell and

Wayne County, in that it failed to apply the adjustment factor contained in section V(C)(4)

of the Standards. See supra note 1. Mr. Gibbs acknowledged that the methodology utilized

by Personal Touch comported with the Authority’s longstanding interpretation of the

Standards, specifically, that the adjustment factor came into play only in situations where

other agencies in a county had received CON approval within the past 12 months. 4 He

argued, however, that the Authority’s interpretation was wrong. In that regard, he testified

that before the Standards were adopted in their final form, HCCRA had developed a sample

application form that applied the adjustment factor in all cases, not just in the limited

       4
          Evidence submitted at the hearing demonstrated that CON approval had been
given in 2002 for provision of home health services where the unmet need in Wayne
County was 69 patients; again in 2002 where the unmet need in Wayne County was 75
patients; in 2003 where the unmet need in Jackson County was 127 patients, the unmet
need in Putnam County was 386 patients, and the unmet need in Lincoln County was 97
patients; again in 2003 where the unmet need in Boone County was 125 patients, the unmet
need in Cabell County was 5 patients, the unmet need in Lincoln County was 98 patients,
the unmet need in Logan County was 180 patients, and the unmet need in Wyoming County
was 212 patients; in 2004, where the unmet need in Berkeley County was 195 patients;
again in 2004, where the unmet need in Wyoming County was 76 patients; in 2008, where
the unmet need in Lincoln County was 30 patients, and the unmet need in Wayne County
was 19 patients; in 2015, where the unmet need in Berkeley County was 961 patients, the
unmet need in Hampshire County was 203 patients, the unmet need in Jefferson County
was 606 patients, the unmet need in Morgan County was 116 patients, and the unmet need
in Mineral County was 130 patients; in 2017, where the unmet need in Pleasants County
was 8 patients, and the unmet need in Tyler County was 6 patients.
                                             5
situation set forth above. He further testified that in 1997, two CON applications that had

been decided by HCCRA 5 had specifically referred to, and applied, the 229 figure as a

threshold, not an adjustment, although he acknowledged that at least since 2002, the

Authority had consistently taken the opposite position. Mr. Gibbs further testified to the

fact that on January 11, 2010, another health care expert, Raymona Kinneberg, then-

advisor to the Authority’s Certificate of Need Director, wrote a letter in which she

expressed agreement with Mr. Gibbs’ opinion, stating that “no new agencies should be

approved in a county where the number of unserved patients was below the threshold set

in the standards, whether or not a new agency had been approved in the previous year.” 6

Mr. Gibbs also opined that what he deemed to be the Authority’s “mistake” ‒ failing to

recognize that the adjustment factor should be applied in all cases ‒ has been perpetuated

in large part by the Authority’s failure to “consider adjusting the threshold adjustment

factor at the time it updates the need calculations[,]” 7 in the 25 years which have elapsed

since the Standards were established. Finally, Mr. Gibbs noted that in 2007, in a CON

       5
         In re: Pro Careers, Inc., CON File No. 96-3/9-5726-Z (Mar. 17, 1997); In re:
Critical Care Nursing Agency, Inc., CON File No. 96-2/3-5790-Z/Z (Mar. 20, 1997).
       6
         Ms. Kinneberg, who later became president of United, now holds a contrary view.
See text infra.
       7
         It appears that Mr. Gibbs’ reference to updating “the needs calculations” was not
a reference to the structure of the methodology, which has never been updated, but to the
population data which is incorporated into the methodology. Although the record is not
entirely clear on this point, it appears that the methodology is updated every two years with
new data. An applicant works from the population data contained in the latest “Home
Health Care Methodology” that the Authority makes publicly available. See text infra.
                                             6
appeal in the Circuit Court of Mason County, 8 the court had held that the Authority’s

interpretation of Section V(C) of the Standards “results in absurd and conflicting decisions”

in that it would be possible “to approve an application where the projection of unmet need

is between 1 and 228 available new patients and also deny one with the same projected

result.” 9 See text infra. Third, Mr. Gibbs testified that with the Amedysis petitioners and

others already providing home health services in Cabell and Wayne Counties, consumers

have adequate choice and no need for additional services. Therefore, in Mr. Gibbs’ view,

the status quo should be maintained.

              On April 4, 2019, the Authority issued its Decision, approving Personal

Touch’s CON application, conditioned on Personal Touch’s submission of annual reports

for the first three years of operation showing “the actual utilization and revenue and

expenses compared to the projections presented[.] In this regard, the Authority specifically

concluded, in relevant part, that “[p]atients will continue to experience serious problems in

obtaining care of the type proposed in the absence of the proposed project,” that “[t]he

project is consistent with the State Health Plan,” and that “[t]he project will serve the

medically underserved population.” The Amedysis petitioners filed a timely Request for

       8
        Effective March 30, 2017, all appeals from a decision of the Office of Judges in a
case involving the grant or denial of a CON are filed in the Circuit Court of Kanawha
County. See id. § 16-2D-16(f).
       9
        Pleasant Valley Hosp., Inc. v. W. Va. Health Care Auth. and Family Home Health
Plus, Inc. dba Ohio Valley Home Health, Inc., No. 06-AA-20, at p. 8 (Mason Cnty. Cir.
Ct. Order dated Mar. 27, 2007).
                                             7
Review by the Health Care Authority/Office of Judges, and on September 28, 2019,

following briefing and argument, the administrative law judge determined “that the

Authority did not err in approving the Personal Touch CON for home health services in

Cabell and Wayne Counties,” and affirmed the April 4, 2019, decision.

              On October 23, 2019, the Amedysis petitioners filed an administrative appeal

in the Circuit Court of Kanawha County. By order entered on February 28, 2020, the court

affirmed the decision of the Office of Judges and specifically found that the “decision is

correct and . . . the Authority did not err in approving the Personal Touch CON for home

health services in Cabell and Wayne counties, West Virginia.” This appeal followed.

No. 20-0401

              In the second case, the Preston Memorial petitioners contend that a CON

issued by the Authority to respondent was improper in that United failed to demonstrate

unmet need for additional home health services in Preston County.

              United is a 292-bed acute care hospital located in Harrison County, West

Virginia. At the time of events relevant to this case, it was the only provider of inpatient

and outpatient acute care in Harrison County, and provided a range of inpatient and

outpatient acute care services in Doddridge County as well. Additionally, United provided

hospital and home health services in Harrison County and surrounding areas, and provided

home health care services in Barbour, Doddridge, Harrison, Lewis, Marion, Taylor, and

                                             8
Upshur Counties. On July 17, 2017, United filed its application for a CON allowing it to

expand its existing home health care services into Preston County. According to the

calculations contained in the application filed by United, which followed the methodology

contained in Section V(C) of the Standards, the unmet need for home health care services

was 44 individuals in Preston County.

             On July 18, 2017, the application was deemed complete, and on August 1,

2017, the Authority issued an Amended Notice of Review. Thereafter, the Preston

Memorial petitioners sought recognition as “affected persons” and asked for a hearing.

Once again, it is important to note that all 5 existing home health care providers in Preston

County, including the Preston Memorial petitioners, had been providing services in Preston

County for more than 12 months preceding the date of United’s application.

              On December 7, 2017, a public hearing was held to determine whether the

application of United for a CON, which would allow it to expand its services into Preston

County, should be granted or denied by the Authority. United put on testimony and

evidence to support its contention that such expansion would be beneficial in a number of

respects. First, because many Preston County patients are released from WVU hospitals

with very complicated needs, home health services provided by United would provide

continuity of care, immediate access to medical records which, in turn, would allow for

better communication and coordination of services, and access to some of WVU hospitals’

medical experts, particularly in the Heart and Vascular Institute. Additionally, United

                                             9
noted that it takes home health services patients who would not be accepted by other

providers, specifically, patients known to be noncompliant and “have a variety of issues

that can negatively affect your quality scores because they use the emergency room, they

get readmitted, they don’t follow their diabetic diet, they don’t take their medications.”

             United also presented testimony and evidence to support its contention that

the proposed expansion of its home health services into Preston County was financially

feasible, in large part by “help[ing] us to reduce readmissions . . . that cost approximately

$2,600 per admission.” Finally, of specific relevance to this appeal, United offered

testimony and evidence to support its projection that in its first year of operation in Preston

County, it would provide services to 44 patients whose need was currently unmet, 10 as well

as to 56 patients shifted from other services already in operation in the county. Testimony

on this issue was given by Raymona Kinneberg, President of United, who supported its

contention that 44 unmet needs patients was sufficient to support its application for a CON,

and that the adjustment factor of 229 unmet needs patients, see text supra, came into play

only in situations where other agencies in a county had received CON approval within the

past 12 months. Ms. Kinneberg acknowledged having once expressed a different opinion

while she was serving as a consultant to the director of the State’s certificate of need

program, but testified that she had changed her view in consideration of two factors: first,

        During the relevant time period, the state home health services utilization rate was
       10

25/1,000 residents; based on its population, Preston County’s need was estimated to be
875, while its actual utilization was 832, leaving unmet need of 44. See text infra.
                                              10
the long, consistent interpretation of the Standards by HCA; and second, the fact that

utilizing the 229 figure as a threshold, rather than an adjustment, would mean that based

on their respective populations, ten counties in West Virginia 11 would never have an unmet

need sufficient to support a CON for any home health services provider to operate therein.

              In response to United’s evidentiary presentation, the Preston Memorial

petitioners put on their own evidence and testimony, including, in relevant part, the

testimony of Charles Gibbs. Mr. Gibbs made the same arguments as he made in the

Amedisys proceedings with respect to the issue of unmet need: specifically, he contended

that using the 229 figure as a threshold in all cases, rather than simply as an adjustment

where an existing provider had received a CON within the past 12 months, balances “the

need for enough providers . . . while recognizing the need to protect financial viability, the

operational viability, and the quality viability . . . [by regulating] the proliferation of home

health systems.” In Mr. Gibbs’ view, the position taken by United, and upheld by HCA,

that an unmet need of 44, or even 1, is sufficient to authorize a CON, is “unreasonable,

absurd and illogical.” Mr. Gibbs also testified that the United project was not financially

feasible, pointing out that United’s own projections showed a $103,915 loss in 2018, a

$96,860 loss in 2019, and a $88,639 loss in 2020, for a total loss of $289,414 over three

       11
         Calhoun, Doddridge, Gilmer, Pendleton, Pleasants, Pocahontas, Tucker, Tyler,
Webster, and Wirt.
                                              11
years. 12 Finally, Mr. Gibbs noted that United had provided no letters of support for its

proposed expansion of home health services into Preston County.

             On February 16, 2018, the Authority issued its Decision, approving United’s

CON application. In this regard, the Authority specifically concluded, in relevant part, that

“[p]atients will continue to experience serious problems in obtaining care of the type

proposed in the absence of the proposed project,” that “[t]he project is consistent with the

State Health Plan,” and that “[t]he project will serve the medically underserved

population.” The Amedisys petitioners filed a timely Request for Review by the Health

Care Authority/Office of Judges, and on June 27, 2018, following briefing and argument,

the administrative law judge determined “that the Authority did not err in approving the

Personal Touch CON for home health services in Preston County,” and affirmed the

February 16, 2018, decision.

              On July 24, 2018, the Preston Memorial petitioners filed an administrative

appeal in the Circuit Court of Kanawha County. By order entered on May 20, 2020, the

       12
          United’s evidence on this point was that expansion of its home health care services
program into Preston County was economically feasible. In this regard, United’s Chief
Financial Officer testified that United had based its financial projections “on how its home
health agency actually operates ‒ as a single unit and not as distinct counties.” Based on
the totality of the evidence, the Authority concluded that “[United] has the resources to
cover any losses initially created by expanding its home health services to Preston County.
The Authority finds that [United] has adequately addressed the Standards as they pertain
to the financial feasibility of this project and this project is financially feasible.”
                                             12
court affirmed the decision of the Office of Judges and specifically found that the decisions

of the Authority and the Office of Judges awarding a CON to United “were supported by

substantial evidence on the whole record; were rendered in accordance with law; were not

arbitrary or capricious; and did not constitute an abuse of discretion or clearly unwarranted

exercise of discretion.” This appeal followed.

                                 II. Standard of Review

             At the initial review level, West Virginia Code § 16-2D-16 provides, in

relevant part, that an appeal is processed by the Office of Judges “in accordance with the

provisions governing the judicial review of contested administrative cases in article five,

chapter twenty-nine-a of this code.” The specific standard of review both for the Office of

Judges and, on appeal therefrom, the circuit court, is set forth in West Virginia Code §

29A-5-4(g) (2016):

                     ‘“‘Upon judicial review of a contested case under the
              West Virginia Administrative Procedure Act, Chapter 29A,
              Article 5, Section 4(g), the circuit court may affirm the order
              or decision of the agency or remand the case for further
              proceedings. The circuit court shall reverse, vacate or modify
              the order or decision of the agency if the substantial rights of
              the petitioner or petitioners have been prejudiced because the
              administrative findings, inferences, conclusions, decisions or
              order are: ‘(1) In violation of constitutional or statutory
              provisions; or (2) In excess of the statutory authority or
              jurisdiction of the agency; or (3) Made upon unlawful
              procedures; or (4) Affected by other error of law, or (5) Clearly
              wrong in view of the reliable, probative and substantial
              evidence on the whole record; or (6) Arbitrary or capricious or
              characterized by abuse of discretion or clearly unwarranted
              exercise of discretion.’ Syllabus point 2, Shepherdstown
              Volunteer Fire Department v. West Virginia Human Rights

                                             13
              Commission, 172 W.Va. 627, 309 S.E.2d 342 (1983).”
              Syllabus, Berlow v. West Virginia Board of Medicine, 193
              W.Va. 666, 458 S.E.2d 469 (1995).’ Syl. Pt. 1, Modi v. West
              Virginia Bd. of Medicine, 195 W.Va. 230, 465 S.E.2d 230
              (1995).

Syl. Pt. 1, W. Va. Med. Imaging & Radiation Therapy Tech. Bd. of Exam’rs v. Harrison,

227 W. Va. 438, 711 S.E.2d 260 (2011).

             Of specific relevance to the instant case, where the petitioners are challenging

the legitimacy of HCA’s interpretation of its own CON Standards, we have held that

                      “‘[j]udicial review of an agency’s legislative rule and
              the construction of a statute that it administers involves two
              separate but interrelated questions, only the second of which
              furnishes an occasion for deference. In deciding whether an
              administrative agency’s position should be sustained, a
              reviewing court applies the standards set out by the United
              States Supreme Court in Chevron U.S.A., Inc. v. Natural
              Resources Defense Council, Inc., 467 U.S. 837, 104 S. Ct.
              2778, 81 L. Ed.2d 694 (1984). The court first must ask whether
              the Legislature has directly spoken to the precise question at
              issue. If the intention of the Legislature is clear, that is the end
              of the matter, and the agency’s position only can be upheld if
              it conforms to the Legislature’s intent. No deference is due the
              agency’s interpretation at this stage.’ Syl. Pt. 3, Appalachian
              Power Co. v. State Tax Dep’t of W. Virginia, 195 W. Va. 573,
              466 S.E.2d 424 (1995).”

Syl. Pt. 5, Murray Energy Corp. v. Steager, 241 W. Va. 629, 827 S.E.2d 417 (2019). If the

intention of the Legislature is not clear, or if the Legislature has not spoken to the specific

issue, this Court will then turn to the second of the two interrelated Chevron questions.

              ‘If legislative intent is not clear, a reviewing court may not
              simply impose its own construction of the statute in reviewing
              a legislative rule. Rather, if the statute is silent or ambiguous
              with respect to the specific issue, the question for the court is

                                              14
              whether the agency’s answer is based on a permissible
              construction of the statute. A valid legislative rule is entitled
              to substantial deference by the reviewing court. As a properly
              promulgated legislative rule, the rule can be ignored only if the
              agency has exceeded its constitutional or statutory authority or
              is arbitrary or capricious. W. Va. Code, 29A–4–2 (1982).’ Syl.
              Pt. 4, Appalachian Power Co. v. State Tax Dep’t of W. Va., 195
              W. Va. 573, 466 S.E.2d 424 (1995).

 Syl. Pt. 6, Murray Energy Corp. v. Steager, 241 W. Va. 629, 827 S.E.2d 417 (2019).

                                      III. Discussion

             In West Virginia Code §§ 16-2D-1 to -20 (2016 & Supp. 2020), the West

Virginia Legislature created the CON program, declaring it to be the State’s public policy

“[t]hat the offering or development of all health services shall be accomplished in a manner

which is orderly, economical and consistent with the effective development of necessary

and adequate means of providing for the health services of the people of this state[,]” and

further to “avoid unnecessary duplication of health services, and to contain or reduce

increases in the cost of delivering health services.” See id. § 16-2D-1(1). Jurisdiction to

administer the CON program was vested in the Authority, see id. § 16-2D-3(a)(1), which

was tasked, inter alia, with “[r]eview[ing] the state health plan, the certificate of need

standards, and the cost effectiveness of the certificate of need program and make any

amendments and modifications to each that it may deem necessary[.]” See id. § 16-2D-

3(a)(2).

                                             15
              Pursuant to the statutory framework, certain health services, including home

health services, must be reviewed and approved by the Authority before they may be

offered to the public in the first instance or expanded into a new area or areas. A certificate

of need may only be issued where the offering or expansion of services is “[f]ound to be

needed; and . . . [c]onsistent with the state health plan, unless there are emergency

circumstances that pose a threat to public health.” See id. §§ 16-2D-12(a)(1), (2). In

making the determination of whether a CON may be issued, the Authority utilizes

Standards which were approved by the Governor and were thereafter in full force and effect

from the date of the Governor’s approval. See id. § 16-2D-6(g). Of note, the Legislature

has formally adopted the Standards and given them “full force and effect.” See id. § 16-

2D-6(g).

             In these consolidated cases, all parties agree that the respondents’ applications

for CONs allowing them to expand their existing home health care services into Cabell,

Wayne, and/or Preston County, were required to be evaluated by the Authority under the

existing Standards. 13 As part of the overall evaluations, the Agency reviewed whether the

respondents had successfully demonstrated the existence of the respective counties’

       13
          Petitioners are highly critical of the fact that the Authority has made no changes
to the Standards, and particularly Section V(C) thereof, since November 13, 1996, the date
on which the Standards were approved by the Governor. However, although there is no
question that the Authority has statutory authority to revise and upgrade the Standards, W.
Va. Code § 16-2D-6, petitioners do not contend that it has a statutory mandate to do so, or
that this Court either could or should force the Authority to act.
                                              16
“unmet need” for services, which was calculated in the first instance, and then on review,

by utilizing the methodology set forth in Section V(C) of the Standards. In this regard, the

“unmet need” that the respondents calculated in Cabell, Wayne, and Preston County, 29,

55, and 44 individuals, respectively, was deemed by the Authority to be sufficient.

Petitioners contended at all stages of the proceedings below, and contend on appeal in their

core assignment of error, 14 that in order to establish “unmet need” a provider must establish

the existence of no fewer than 229 individuals needing services. In this regard, the

petitioners argue that the Authority’s interpretation of the Standards, and particularly

section V(C)(4) thereof, “Calculation of the Threshold (Adjustment Factor),” is “[c]learly

wrong in view of the reliable, probative and substantial evidence on the whole record; or .

. . [a]rbitrary or capricious or characterized by abuse of discretion or clearly unwarranted

exercise of discretion.” W. Va. Med. Imaging, 227 W. Va. at 440, 711 S.E.2d at 262, Syl.

Pt. 1, in part. As set forth above, the Authority’s consistent and longstanding interpretation

of the procedures set forth in Section V(C), is that the figure of 229 individuals in need of

home health care is an adjustment factor that comes into play only where an applicant seeks

a CON in a county or counties where another provider received a CON within the preceding

12 months. The adjustment, says the Authority, is intended to give relatively new providers

an opportunity to develop a client base before facing competition from brand new

providers. In contrast, petitioners claim that the figure is a threshold factor, specifically:

       14
         Although the petitioners break the issue down into multiple parts, which this Court
will address in turn, there is really only one issue: whether the Authority’s interpretation
of Section V(C) of the Standards is entitled to deference. See text infra.
                                             17
that whether or not another provider or providers received a CON within the preceding 12

months, no CON can be granted unless the unmet need in a county or counties equals or

exceeds 229 individuals.

             In order to address this issue, we first look at section V(C), “Determining

Unmet Need for Home Health Services,” as a whole. This determination, which is made

for any county in which a home health care provider seeks a CON, requires an applicant to

make three or four separate calculations which are set forth in four discrete subsections.

Of note, however, the following language is contained in the general overview which

precedes those subsections:

              Calculation 1 compares the county and state home health
              utilization rates.

              Calculation 2 determines the extent of potential home health
              recipients in the county to reach the state utilization level.

              Calculation 3 determines the extent of potential home health
              recipients in the county to reach the state utilization level.

              Calculation 4 involves an adjustment factor for the agencies
              receiving Certificate of Need approval in the previous 12
              months to allow for their initiation and development of home
              health services. Each agency is allowed a 229-home health
              recipient adjustment factor for each county in the approved
              service area. An unmet need or threshold of at least 229
              projected home health recipients must occur in the county
              before consideration will be given to issuing another
              Certificate of Need for the County.

(Emphasis added). With this overview in mind, we turn to the subsections describing the

particular calculations to be made.

                                           18
              First, subsection (1), “Calculation of the Actual Total County Home Health

Utilization Rate,” sets forth the methodology for calculating a county’s home health care

utilization rate, which is expressed as a fraction: the number of persons needing home

health care services per 1,000 citizens in the county. To find this rate, the number of home

health care recipients in a county is divided by the county’s population for the same year,

then multiplied by 1,000 in order to arrive at the county’s home health care utilization rate.

It is undisputed that based on fiscal year 2015 population data, which was contained in the

methodology utilized in the Personal Touch application, the utilization rate in Cabell

County was 27.5/1000 and the utilization rate in Wayne County was 26.5/1000, while the

state utilization rate was 27.8/1000. 15 It is further undisputed that based on fiscal year 2017

population data, which was contained in the methodology utilized in the United

application, the utilization rate in Preston County was 23.7/1000, while the state utilization

rate was 25/1000. Pursuant to substandard V(C)(1), if a county’s utilization rate is above

the state rate, then that is the end of the inquiry; an unmet need does not exist. If the

county’s utilization rate is below the state rate, then the CON applicant goes on to

subsection (2). In these consolidated cases, all of the counties’ utilization rates were below

the state rates for the years in question.

       15
          While the Amedisys petitioners do not contest any of the V(C)(1) – (3)
calculations in terms of the mathematics, they do contest the legitimacy of utilizing fiscal
year 2015 data when, according to their expert witness, fiscal year 2017 data was available
at the time Personal Touch filed its application for a CON. See text infra.
                                              19
             Subsection (2), “Calculation of the Actual Number of Home Health

Recipients Needed to Obtain the State Utilization Rate,” sets forth the methodology for

calculating the actual number of home health recipients needed to bring a county’s

utilization rate in line with the state’s rate. To make the calculation: the number of home

health care recipients in a county in a particular year is multiplied by the state utilization

rate for that year, after which the resulting number is then divided by the county utilization

rate for the year. It is undisputed that based on data from fiscal year 2015, the number of

recipients needed to bring Cabell County’s utilization rate into line was 2,687 and the

number needed to bring Wayne County’s utilization rate into line was 1,139. It is further

undisputed that based on data from fiscal year 2017, the number of home health recipients

needed to bring Preston County’s utilization rate into line was 875.

             Subsection (3), Calculation of the Actual Number of Home Health Recipients

Below the State Rate,” sets forth the methodology for calculating the actual number of

home health recipients below the state utilization rate. To make the calculation: the number

of home health care recipients in a county, set forth in subsection (1), is subtracted from

the number of home health care recipients needed to bring the county’s utilization rate in

line with the state’s rate, set forth in subsection (2). It is undisputed that in 2017, the

number of recipients below the state utilization rate in Cabell County was 29 and the

number below the state rate in Wayne County was 55. It is further undisputed that in 2018,

the actual number of home health care recipients below the state utilization rate in Preston

County was 44.

                                             20
              It is at this point in the calculation that the parties’ unanimity breaks down.

In order to understand their respective arguments, we will set forth subsection (4) verbatim.

       CALCULATION OF THE THRESHOLD (ADJUSTMENT
       FACTOR)
       (This calculation is done only if there are agencies in the proposed
       county which received CON approval in the previous 12 months.)

       Formula a – b = c

       a. List the current county home health recipients below state
       b.   Subtract adjustment factor for agencies receiving CON
       approval in previous 12 months.
       c. Number above threshold adjustment

Conclusion:
If the threshold is at least 229 projected home health recipients, an
unmet need exists.

             Petitioners contend that the key here is in both the placement and the language

of the Conclusion. First, they argue that its un-indented position on the page sets it apart

from the subsection (4) formula, and thus it is logically a conclusion to Section V(C) of the

Standards, “Determining Unmet Need for Home Health Services,” in its entirety, not just

to subsection V(C)(4), “Calculation of the Threshold (Adjustment Factor).” Second, they

argue that the preceding argument is buttressed by the use of the word “threshold” and the

correlative omission of the word “adjustment” in the Conclusion. Therefore, petitioners

sum up, regardless of the existence of non-existence of any other providers, and regardless

of how long any such providers have been in business, an applicant for a CON must

demonstrate that there are at least 229 individuals in the county in need of home health care

services.   Respondents Personal Touch, United, and the Authority counter that in the

                                             21
overview language of Section V(C), it is specifically stated that the 229 figure is “an

adjustment factor for the agencies receiving [CON] approval in the previous 12 months to

allow for their initiation and development of home health services.” (Emphasis added).

Further, respondents cite the language of subsection V(C)(4), specifically, that “[t]his

calculation is done only if there are agencies in the proposed county which received CON

approval in the previous 12 months.” (Emphasis added). Additionally, respondents note

the unchallenged testimony of Raymona Kinneberg that if the 229 figure were interpreted

to be a threshold, rather than an adjustment, 10 counties in West Virginia are so sparsely

populated that a CON could never be approved for the provision of home health care

services for their residents. See supra note 11.

             Having addressed the parties’ respective factual contentions in broad terms,

we now turn to the petitioner’s overarching, interrelated legal arguments: that the

Authority’s interpretation of the Standards, specifically, that the 229 figure is an adjustment

factor rather than a threshold factor, is arbitrary, capricious, and clearly erroneous, and

therefore not entitled to deference by this Court; and that on de novo review, this Court

should find the 229 figure to be a threshold factor. In this regard, this Court has adopted

the two-part test of Chevron U.S.A., Inc. v. Nat. Res. Def. Council, 467 U.S. 837 (1984),

which “first ask[s] whether the Legislature has ‘directly spoken to the precise [legal]

question at issue.’” Appalachian Power, 195 W. Va. at 582, 466 S.E.2d at 433. Here,

petitioners concede that because the Standards were drafted by the Authority’s predecessor,

                                              22
HCCRA, not by the Legislature, the first prong of the Chevron analysis is not applicable.

We therefore turn to the second prong of Chevron, which asks “whether the agency’s

answer is based on a permissible construction of the [Standards].” Id. In determining that

issue, we have held that “[a] valid legislative rule is entitled to substantial deference by the

reviewing court. As a properly promulgated legislative rule, the rule can be ignored only

if the agency has exceeded its constitutional or statutory authority or is arbitrary or

capricious.” Murray Energy Corp. v. Steager, 241 W. Va. at 632, 827 S.E.2d at 419, Syl.

Pt. 6, in part. However, if it is determined that an agency’s interpretation of its regulations

is not entitled to Chevron deference, then we may interpret the regulations pursuant to our

well-established rule that “‘[i]nterpreting a statute or an administrative rule or regulation

presents a purely legal question subject to de novo review.’ Syl. Pt. 1, Appalachian Power

Co. v. State Tax Dep’t of W. Va., 195 W. Va. 573, 466 S.E.2d 424 (1995).” Syl. Pt. 2,

Steager v. Consol Energy, Inc., 242 W. Va. 209, 832 S.E.2d 135 (2019).

                                              23
              In support of both their deference and de novo review arguments, 16 petitioners

contend that common sense, “whole-text analysis,” 17 the Merriam-Webster Dictionary, 18

and a grammatical analysis made by the late United States Supreme Court Justice Antonin

Scalia, 19 all mandate a finding that the word “Conclusion” at the end of Section subsection

V(C)(4) of the Standards, “[i]f the threshold is at least 229 projected home health

       16
           This Court has long recognized the deference/de novo dichotomy which is present
in all of the cases where the issue is an agency’s interpretation of a statute it is required by
law to enforce and/or a regulation it has promulgated as part of that process. See, e.g., W.
Va. Consol. Pub. Ret. Bd. v. Wood, 233 W. Va. 222, 228, 757 S.E.2d 752, 758 (2014)
(“While this Court agrees with the proposition that the [agency’s] interpretation is entitled
to deference, it is imperative that a reviewing court also consider the possibility . . . that
the [agency’s] interpretation is erroneous.”).

       17
          See Weirton Med. Ctr., Inc. v. W. Va. Bd. of Med., 192 W. Va. 72, 75, 450 S.E.2d
661, 664 (1994) (“It is a cardinal rule of statutory construction that a statute should be
construed as a whole, so as to give effect, if possible, to every word, phrase, paragraph and
provision thereof, but such rule of construction should not be invoked so as to contravene
the true legislative intention.’”) (citation omitted).

       18
           Petitioners note that there are three references in the Standards to a
“threshold/adjustment” factor, and that the forward slash, or virgule, between the two
words is significant because the word virgule is defined in the online version of the
Merriam-Webster Dictionary as “a short oblique stroke between two words indicating
whichever is appropriate may be chosen to complete the sense of the text in which they
occur.” Thus, according to petitioners, when the word “adjustment” is used in V(C) and
V(C)(4), the word should be interpreted to mean “threshold” since that would be
“appropriate . . . to complete the sense of the text[.]” Inasmuch as there is no virgule in
any of the relevant provisions of V(C), we decline to follow petitioners down this linguistic
rabbit hole.
       19
         Antonin Scalia & Bryan A. Garner, Reading Law: The Interpretation of Legal
Texts 156 (2012) (“Material within an indented subpart relates only to that subpart;
material contained in un-indented text relates to all the following or preceding indented
subparts.”).
                                              24
recipients, an unmet need exists[,]” applies to the entirety of the four-step process for

determining unmet need, not just to the fourth step. This result obtains, say petitioners,

because (a) none of the other subsections are followed by a “Conclusion,” suggesting that

the one and only “Conclusion” in Section V(C) must apply to the entire calculation; (b) the

“Conclusion” is not marginally aligned with the text of subsection V(C)(4), and thus cannot

be deemed to be a part of that text; and (c) the overview language of Section V(C) includes

the statement that “[t]he four calculations must be completed for each county to be served,”

suggesting that the fourth calculation applies in every CON cases, not just in those where

a CON has been issued to another provider within the past 12 months. Additionally,

petitioners claim, albeit in an oblique fashion, that absent a threshold of 229 individuals to

establish unmet need, the Standards would not meet the objectives set forth in West

Virginia Code § 16-2D-1, particularly the “avoid[ance of] unnecessary duplication of

health services.”

             We are unpersuaded that these scattershot arguments are sufficient to

overcome the specific directive in the overview language of Section V(C) that

“[c]alculation 4 involves an adjustment factor for the agencies receiving Certificate of

Need approval in the previous 12 months to allow for their initiation and development of

home health services[,]” and the specific directive in subsection V(C)(4) that “[t]his

calculation is done only if there are agencies in the proposed county which received CON

                                             25
approval in the previous 12 months.” (Emphasis added). 20 We are further unpersuaded

that the placement of the “Conclusion” in subsection (C)(4) in un-indented text, see supra

note 19, has any significance. In this regard, we note that the “Calculation of the Actual

Total County Home Health Utilization Rate,” set forth in subsection V(C)(1) of the

Standards, is set up in a manner identical to V(C)(4): following an indented six-step

analysis whose purpose is to determine whether a county’s home health utilization rate is

below the state rate, we find the following, un-indented, line: “If yes, continue with the

following. If no, an unmet need does not exist.” Likewise, we are unpersuaded that

petitioners’ argument is supported by common sense, in light of the undisputed testimony

that if an unmet need of 229 individuals were needed to support the issuance of a CON, ten

counties in West Virginia would never be able to meet the 229 threshold.

             In addition, the petitioners give no weight at all to the undisputed fact that for

at least 20 years, the Authority has consistently interpreted the 229 figure as an adjustment

factor, not a threshold factor, and accordingly has consistently interpreted subsection

V(C)(4) of the Standards to apply only in cases where another provider has received a CON

within the 12 months preceding a new application. 21 In this regard, we have held that

       20
          As previously noted, because no virgule appears in these directives, we will not
linger over petitioners’ complex linguistic argument that its appearance elsewhere in the
Standards somehow transforms the word “adjustment” into “threshold.”

       21
         Petitioners put on evidence to show that the Authority’s predecessor, HCCRA,
seemed to embrace petitioners’ view while the Standards were being developed, by affixing
                                             26
                     [i]nconsistency is only one of many circumstances that
              this Court should consider in determining deference. The
              factors most often recognized by courts as to whether to defer
              to administrative interpretations were set out by Colin S. Diver
              in Statutory Interpretation in the Administrative State, 133 U.
              Pa. L. Rev. 549, 562 n. 95 (1985). He lists them as

                      “(1) whether the agency construction was
                     rendered contemporaneously with the statute's
                     passage, ... (2) whether the agency’s construction
                     is of longstanding application, ... (3) whether the
                     agency has maintained its position consistently
                     (even if infrequently), ... (4) whether the public
                     has relied on the agency’s interpretation, ... (5)
                     whether the interpretation involves a matter of
                     ‘public controversy,’ ... (6) whether the
                     interpretation is based on ‘expertise’ or involves
                     a ‘technical and complex’ subject, ... (7) whether
                     the agency has rulemaking authority, ... (8)
                     whether agency action is necessary to set the
                     statute in motion, ... (9) whether ... [the
                     Legislature] was aware of the agency[‘s]
                     interpretation and failed to repudiate it, ... and
                     (10) whether the agency has expressly addressed
                     the application of the statute to its proposed
                     action[.]” (Citations omitted).

Appalachian Power, 195 W. Va. at 591 n.24, 466 S.E.2d at 442 n.24.

            Finally, with respect to petitioners’ intimation that the Authority’s

interpretation of the Standards allows for the unnecessary duplication of home health

services in counties such as Cabell, Wayne, and Preston, we note that there is no empirical

evidence in the appendix record to support such a claim. Additionally, although the Preston

to the draft Standards a sample calculation that treated 229 as a threshold figure. However,
HCCRA somehow “omitted” ‒ whether intentionally or inadvertently ‒ putting that sample
calculation into the final version of the Standards that was signed by the Governor.
                                             27
Memorial petitioners attempted to show at the hearing before the Authority that the

existence of a new home health provider in Preston County would result in some

“poaching” of the Preston Memorial petitioners’ existing patients, and that United’s plan

for providing services in Preston County was not cost-effective, the petitioners did not list

these alleged errors, directly or indirectly, in an assignment of error. Therefore this Court

will disregard them on appeal. See Rule 10(c)(3) of the West Virginia Rules of Appellate

Procedure. 22

                Building on the preceding arguments, all of which analyze the language,

placement, and punctuation of Section V(C) of the Standards through the lens of an English

academician, petitioners next contend that in 2007, the Circuit Court of Mason County

found, on facts materially similar to those in the instant consolidated cases, that the 229

       22
            This Court recently discussed the importance of assignments of error, cautioning
that

                 a petitioner’s presentation of an assignment of error allows a
                 respondent to address the focused issue, confident that he did
                 not fail to discern a determinative argument buried in
                 petitioner’s prose. This courtesy is imperative to equitable
                 function, averting the danger that the Court and respondent
                 may discern different issues from a petitioner's lengthy, free-
                 flowing argument. This benefit, in turn, inures to the petitioner,
                 ensuring that a responsive pleading does not throw the appeal
                 into an unexpected rabbit hole.

Wilson v. Kerr, No. 19-0933, 2020 WL 7391150, at *3 (W. Va. Dec. 16, 2020)
(memorandum decision).

                                                28
figure for unmet need was a threshold that all CON applicants must meet, not just an

adjustment factor to be applied where another provider had received a CON in the

particular county within the past 12 months. Pleasant Valley Hosp., Inc. v. Fam. Home

Health Plus, Inc., d/b/a Ohio Valley Home Health, Inc., No. 06-AA-20 (Cir. Ct. of Mason

Cnty., Mar. 27, 2007), appeals denied, Nos. 073947 and 073948 (W. Va. Sup. Ct. Apr. 3,

2008). We may dispose of this argument without extended discussion. First, to the extent

petitioners are trying to claim that the Mason County case has precedential value because

of this Court’s denial of the appeals therefrom, we have clearly held to the contrary: “This

Court’s rejection of a petition for appeal is not a decision on the merits precluding all future

consideration of the issues raised therein[.]” Syllabus, in part, Smith v. Hedrick, 181 W.

Va. 394, 382 S.E.2d 588 (1989). Second, petitioners have given this Court no principled

basis on which to conclude that the analysis of the court in Pleasant Valley Hospital was

any more cogent, insightful, or scholarly than the contrary analysis of the two courts in the

cases below. Third, as is clear from the analysis herein, we disagree with the conclusion

reached by the court in the Pleasant Valley Hospital case and disagree with petitioners’

sweeping assertion that “the [court’s] interpretation of the Home Health Standards is the

only correct interpretation.”

              The petitioners’ next argument is ostensibly about health planning and public

policy considerations, but in reality is merely a compilation of online information which

purports to demonstrate that there exists (a) a “precipitous expansion of services by new

providers in twenty-five counties” in West Virginia, and (b) a disconnect between the

                                              29
Authority’s standard for unmet need in home health services and its standard for unmet

need in other areas of health care. 23 Our examination of the voluminous appendix record

submitted by the parties demonstrates that no empirical data to support these contentions

was submitted to the Authority at either the Amedisys petitioners’ public hearing or the

Preston Memorial petitioners’ public hearing, and therefore none of it was considered by

either the Office of Judges or the circuit courts. Further, at oral argument respondents’

counsel stated categorically that the number of home health care service providers is far

fewer than existed at the time the Standards were established in 1995, in large part because

of the consolidation of smaller providers into large nationwide providers such as Amedisys.

             We need not resolve these factual disputes because it is a bedrock principle

of appellate jurisprudence that “representations in an appellate brief do not constitute a part

of the record on appeal.” Pearson v. Pearson, 200 W. Va. 139, 152, 488 S.E.2d 414, 427

(1997) (Workman, J., dissenting) (citing Wilkinson v. Bowser, 199 W.Va. 92, 483 S.E.2d

92 (1996)). And in any event, the Legislature has delegated matters involving public health

to the Authority, see id. § 16-2D-1 to -20, which has the institutional expertise needed to

resolve difficult issues of public health and citizens’ access to public health services. In

this regard, we have held that this Court’s review of an agency determination

       23
          Petitioners cite to internet sources for information on the Authority’s standards
governing unmet need for computed tomography; cardiac surgery; hospice services;
megavoltage radiation therapy; positron emission tomography; fixed magnetic resonance
imaging; in-home personal care; intermediate care facilities for individuals with
intellectual disabilities; and end stage renal disease.
                                              30
              must be performed with conscientious awareness of its limited
              nature. The enforced education into the intricacies of the
              problem before the agency is not designed to enable the court
              to become a superagency that can supplant the agency’s expert
              decision-maker. To the contrary, the court must give due
              deference to the agency’s ability to rely on its own developed
              expertise. The immersion in the evidence is designed solely to
              enable the court to determine whether the agency decision was
              rational and based on consideration of the relevant factors.

Princeton Cmty. Hosp. v. State Health Plan., 174 W. Va. 558, 564, 328 S.E.2d 164, 171

(1985) (citation omitted); cf. Appalachian Power, 195 W. Va. at 582, 466 S.E.2d at 433

(“An inquiring court ‒ even a court empowered to conduct de novo review ‒ must examine

a regulatory interpretation of a statute by standards that include appropriate deference to

agency expertise and discretion.”). Given the Authority’s longstanding interpretation of

the particular Standard at issue, Section V(C) and more specifically subsection V(C)(4),

this Court will not presume to second-guess a policy which has only been challenged three

times in 25 years – with only one “win” for the position espoused by the petitioners, a

decision that has no precedential value since this Court denied the appeal therefrom

pursuant to our prior practice. 24

              In consideration of the foregoing, we hold that where the State Health Plan

Home Health Services Standards were promulgated by the West Virginia Health Care

       24
         The current Rules of Appellate Procedure were promulgated and adopted by this
Court on October 19, 2010, and were effective December 1, 2010. The Clerk’s comments
to Rule 21, Memorandum decisions, note that “[t]he ability to enter memorandum
decisions ‒ rather than refusal orders under prior practice ‒ is at the core of the revised
process: every appeal, unless dismissed, will result in a decision on the merits.”
                                            31
Authority (formerly the West Virginia Health Care Cost Review Authority) pursuant to a

legislative grant of authority, West Virginia Code §§ 16-2D-1 to -20 (2016 & Supp. 2020),

authorized by the Governor, and formally adopted and given full force and effect by the

Legislature, see id. § 16-2D-6(g), the longstanding, consistent interpretation of those

Standards by the West Virginia Health Care Authority, being neither arbitrary nor

capricious, is entitled to judicial deference pursuant to Chevron U.S.A., Inc. v. Natural

Resources Defense Council, Inc., 467 U.S. 837 (1984).

             Finally, the Amedisys petitioners contend that the Authority erred in granting

a CON to Personal Touch because the data upon which the Section V(C) calculations were

based was not “the most recent home health survey data” available. In this regard, Personal

Touch utilized a methodology containing 2015 data, rather than utilizing 2017 data which

had been collected and aggregated by the Authority from a 2018 survey and made public

in or about June, 2018, prior to the date of Personal Touch’s application. Petitioners’ expert

witness, Mr. Gibbs, testified that if the 2017 data had been utilized, the V(C) calculations

would have demonstrated that the unmet need in Cabell County had actually declined to -

195. In response, the respondents point out that it is the Authority, not the applicant, which

performs the unmet need calculations, and that at the time the Personal Touch application

was prepared and filed, the “2015 Home Health Care Methodology” was the most current

methodology available. In that regard, the Authority states in its brief that even if the raw

2017 data from the 2018 survey results was available in June, 2018, the “2017 Home Health

                                             32
Need Methodology” was not available for use until December 8, 2018 ‒ months after the

Personal Touch application had been submitted.

             Petitioners point to no statute, regulation, or case from this Court requiring an

applicant to use available raw data rather than the data contained in the Authority’s most

current “Hone Health Need Methodology.” Therefore, in accepting the calculations

contained in the Personal Touch application, the agency cannot be said to “ha[ve] exceeded

its constitutional or statutory authority or [to be] arbitrary or capricious[,]” Murray Energy,

241 W. Va. at 631, 827 S.E.2d at 419, Syl. Pt. 6, in part.

                                       IV. Conclusion

       For the foregoing reasons, the decisions of the circuit court in No. 20-0308 and No.

20-0401, consolidated for purposes of this appeal, are affirmed.

                                                                                    Affirmed.

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