N.C. Appeals Court Overturns Decision Denying Medicaid Coverage Of Chemotherapy As Treatment For Emergency Condition

IMMIGRANTS & PUBLIC BENEFITS

Health Care

N.C. APPEALS COURT OVERTURNS DECISION DENYING MEDICAID COVERAGE OF CHEMOTHERAPY AS TREATMENT FOR EMERGENCY CONDITION
Immigrants' Rights Update, Vol. 18, No. 1, February 17, 2004

A North Carolina court of appeals recently overturned a lower court's ruling that an immigrant's inpatient chemotherapy treatments were not within the scope of an "emergency medical condition" under the state and federal Medicaid laws. Medicaid for emergency medical conditions is available to eligible individuals, including undocumented persons, without regard to immigration status. Like the Arizona Supreme Court's recent decision in Scottsdale Healthcare, Inc. v. Arizona Health Care Cost Containment System Administration, 75 P.3d 91 (Ariz. 2003) (see "'Emergency Medical Condition' Given Generous Interpretation by Arizona Court," IMMIGRANTS' RIGHTS UPDATE, Sept. 4, 2003, p. 11), the case has national significance because it interprets a provision of federal Medicaid law that is applicable in each state's Medicaid program. North Carolina provides emergency Medicaid

(c) . . . for care and services necessary for the treatment of an emergency condition if:

(1) the alien requires the care and services after the sudden onset of a medical condition (including labor and delivery) that manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical treatment could result in

(A) Placing the patient's health in serious jeopardy,
(B) Serious impairment to bodily functions, or
(C) Serious dysfunction of any bodily organ or part.

N.C. Admin Code tit. 10, r. 50B.0302 (June 2002).

This language follows closely the U.S. Dept. of Health and Human Services regulation defining an emergency medical condition, 42 CFR sec. 440.255(b).

The petitioner in the case before the court was Benito Luna, an undocumented immigrant who was diagnosed with a cancerous tumor on his spine. Luna's tumor was surgically removed, and he was discharged from the hospital after rehabilitation, then readmitted on seven separate occasions for scheduled inpatient chemotherapy treatments. The state Medicaid agency approved Luna's application for emergency Medicaid for his surgery. However, the agency denied the emergency Medicaid coverage for the chemotherapy treatments on the ground that the chemotherapy was not provided to address an emergency medical condition. The lower court agreed with the agency's interpretation and denied coverage for the chemotherapy treatments.

The lower court set forth several conclusions, including findings that "[e]mergency medical conditions do not include chronic debilitating conditions resulting from the initial event which later require ongoing regimented care" and that "[t]he potentially fatal consequences of discontinuing ongoing care, even if such care is medically necessary, does not transform the Petitioner's condition into an emergency medical condition."

The court of appeals rejected the lower court's decision. The appellate court concluded that it was an issue of medical fact whether Luna's chemotherapy was treatment for a "chronic debilitating condition" or a necessary course of treatment for his initial emergency medical condition, and that the lower court had failed to establish the facts necessary to support its conclusion. "The factual question to be addressed," according to the appellate court, "is whether the absence of 'immediate medical attention' . . . could result in one or all of the three consequences listed in the [state emergency Medicaid] regulation." The court of appeals further rejected the lower court's claim that the potentially fatal consequences of denying necessary care do not transform a condition into an emergency, concluding that this finding directly contravened the regulation.

The court distinguished Luna's situation, in which he sought care for "a finite course of treatment of the very condition that sent him to the emergency room," from cases involving patients with chronic conditions. These cases include The Greenery Rehabilitation Group, Inc. v. Hammon, et al., 150 F.3d 226 (2d Cir. 1998), a leading case on the interpretation of "emergency medical condition" in the Medicaid Act. The appellate court concluded that the analysis by the Arizona Supreme Court in Scottsdale was most applicable, because of the similar facts, identical statutory language, and clarity of guidance provided by the decision.

The court of appeals remanded the case to the lower court with instructions to resolve, as a matter of fact, (1) whether, at the time he sought the services at issue, Luna's condition was manifesting itself by acute symptoms, and (2) whether the absence of immediate medical attention could reasonably be expected to place his health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of any bodily organ or part.

Benito Luna v. Division of Social Services, 589 S.E. 2d 917 (N.C. Ct. App. 2004).