State of North Carolina s178
STATE OF NORTH CAROLINA IN THE OFFICE OF
ADMINISTRATIVE HEARINGS
COUNTY OF CUMBERLAND 03 DHR 0099
VALENCIA L. BROWN, )
Petitioner, )
)
v. ) DECISION
)
N. C. DIVISION OF MEDICAL )
ASSISTANCE (DMA), )
Respondent. )
This contested case was commenced by the filing of a petition on January 29, 2003. It came on for hearing before the undersigned administrative law judge on June 10, 2003, in Fayetteville, North Carolina. The petitioner appeared, pro se. Emery E. Milliken, Assistant Attorney General, appeared on behalf of the respondent.
ISSUE
Whether the respondent properly denied prior approval for Medicaid coverage for
bilateral breast reduction surgery for petitioner?
APPLICABLE LAW
Sections1905(d); 1905(a)(15); 1902(i)(1) of the Social Security Act
N. C. Gen. Stat. Ch. 108A, Article 2, Parts 1 and 6
N. C. State Plan for Medical Assistance
10 N.C.A.C. 26C .0005
10 N.C.A.C. 26G .0104(d)
North Carolina Rules of Civil Procedure
FINDINGS OF FACT
1. The parties received notice of the hearing more than 15 days prior to the hearing date and notice of the hearing was in all respects proper.
2. The petitioner requested prior approval for Medicaid coverage for bilateral breast reduction surgery.
3. The respondent is the agency responsible for administering North Carolina's medical assistance (Medicaid) program.
4. Petitioner testified that although she has been trying to lose weight and has in fact lost weight, that she knows that her current weight is above the allowable maximum weight range for her height in order to have the bilateral breast reduction surgery approved.
5. Petitioner testified that she did not have evidence to document and prove that she meets the legal requirements to receive prior approval from respondent for the bilateral breast reduction surgery.
6. Petitioner’s documentation does not support the need for bilateral breast reduction surgery.
7. At the close of petitioner’s evidence, respondent moved for a directed verdict in favor of respondent which motion was granted.
CONCLUSIONS OF LAW
1. The parties are properly before the Office of Administrative Hearings (OAH) and OAH has jurisdiction over the subject matter involved in this contested case.
2. The burden of proof is upon petitioner to show that the requested surgery is medically necessary and that she meets the legal requirements to receive prior approval from respondent for the bilateral breast reduction surgery.
3. Petitioner failed to satisfy this burden.
DECISION
Based upon the foregoing findings of fact and conclusions of law, the undersigned hereby determines that respondent’s decision to deny prior approval for Medicaid coverage for bilateral breast reduction surgery for petitioner is AFFIRMED.
ORDER
It is hereby ordered that the agency serve a copy of the FINAL DECISION on the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6714, in accordance with North Carolina General Statute 150B-36(b).
NOTICE
The North Carolina Health and Human Services, Division of Medical Assistance, will make the Final Decision in this contested case. N.C.G.S. § 150B-36(b), (b1), (b2), and (b3) enumerate the standard of review and procedures the agency must follow in making its Final Decision, and adopting and/or not adopting the Findings of Fact and Decision of the Administrative Law Judge.
Pursuant to N.C.G.S. § 150B-36(a), before the agency makes a Final Decision in this case, it is required to give each party an opportunity to file exceptions to this decision, and to present written arguments to those in the agency who will make the Final Decision. N.C.G.S. § 150B-36(b)(3) requires the agency to serve a copy of its Final Decision on each party, and furnish a copy of its Final Decision to each party’s attorney of record and to the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, N.C. 27699-6714.
This the 17 day of November, 2003.
______
Sammie Chess, Jr.
Administrative Law Judge