An Indiana Medicaid recipient’s request for genetic testing will go back to the Indiana Family and Social Services Administration (FSSA) for review, after an appellate court remanded her appeal. The recipient’s request was denied by an administrative law judge (ALJ) as not covered by Medicaid due to lack of medical necessity and the decision was affirmed by the trial court. The FSSA conceded that the ALJ’s reasoning was flawed and the appellate court remanded the case to the FSSA for a fact-finding hearing to determine whether the treatment was new or experimental and whether it was medically necessary (Brown v. Indiana Family and Social Services Administration, February 16, 2017, Crone, T.).
A mother of three underwent surgery to remove a benign paraganglioma, a type of rare neuroendocrine tumor. Because one-third to one-half of such tumors are associated with inherited symptoms, including Hereditary Paraganglioma-Pheochromocytoma (PGL/PCC) Syndrome, her physicians recommended that she undergo genetic testing; if she tested positive for PGL/PCC Syndrome, they recommend that her children also be tested. All those affected would then undergo regular screening. The Medicaid recipient’s managed care organization (MCO) acknowledged that the genetic testing was "medically indicated," but denied prior authorization because it was not covered by Medicaid.
An ALJ noted that the Indiana Administrative Code (IAC) did not exclude PGL/PCC Syndrome genetic testing from Medicaid coverage, but that the Indiana Health Coverage Programs (IHCP) Manual identified PGL/PCC Syndrome genetic testing current procedural terminology (CPT) codes as not covered. The ALJ then determined that the service was "not medically necessary" pursuant to 405 IAC 5-29-1, because, while it was not listed as a noncovered service, it was "otherwise excluded from coverage" (405 IAC 5-2-17). The FSSA affirmed the ALJ’s decision and the trial court denied the recipient’s petition. She appealed.
The FSSA conceded to the appellate court that the ALJ’s legal reasoning was erroneous and that, in fact, the genetic testing was not covered because it was a new or experimental treatment pursuant to 405 IAC 5-29-1(3) and (4), acknowledged that the new or experimental status could have changed since the ALJ’s decision, and asked the court to vacate the decision and remand it for a new fact-finding hearing. Acknowledging the Medicaid recipient’s argument that the FSSA will also need to make an individualized determination regarding medical necessity, the appellate court vacated the decision and remanded it to the FSSA for a rehearing.
The case is No. 82A05-1603-PL-688.
Attorneys: Katherine J. Rybak (Indiana Legal Services, Inc.) for Ashley Brown. Curtis T. Hill, Jr., Attorney General of Indiana, for Indiana Family and Social Services Administration.
Companies: Indiana Family and Social Services Administration
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