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Tennessee Appeals Court Affirms Denial Of TennCare Coverage For Home Health Services Found Not To Be Medically Necessary

 
 

HLD, v. 30, n. 8 (August 2002)

Tennessee Appeals Court Affirms Denial Of TennCare Coverage For Home Health Services Found Not To Be Medically Necessary

Carolyn Jones, who is bed-ridden due to rheumatoid arthritis, had been receiving coverage for home health services as an enrollee of the Bureau of TennCare (TennCare). In November 1997, TennCare's managed care organization, Blue Care, informed Jones that it would no longer cover the cost of her home health services because they constituted "custodial care--not medically indicated." Following an administrative hearing, an Administrative Law Judge (ALJ) concluded that TennCare had shown by a preponderance of the evidence that the services at issue, which included personal grooming assistance and light housekeeping, were not medically necessary and therefore not covered. After a final agency order affirming the ALJ's decision, Jones filed an appeal in state trial court. The trial court affirmed and Jones appealed.

The Tennessee Court of Appeals affirmed. In so holding, the appeals court rejected Jones' argument that, because TennCare had provided home health coverage to her in the past, it had to show a "change in circumstances" before discontinuing coverage. Rather, the appeals court said, "Jones' position on this issue is contrary to the clear legislative intent to provide benefits only for covered services." Next, the appeals court addressed Jones' contention that BlueCare and TennCare impermissibly changed the definition of "medically necessary" to exclude "unskilled" services for home healthcare in violation of federal law. The appeals court agreed with Jones that applicable federal and state statutes and regulations make no "skilled/unskilled care" distinction. On the contrary, the appeals court said, "Medicaid regulation 42 C.F.R. � 440.70(b)(1) & (2), shows the home health services that a state is required to provide include both skilled nursing services and unskilled home health aide services." The appeals court noted that the ALJ's decision made no reference to such a distinction, but rather held that, based on the evidence presented, Jones' home health services were not medically necessary. "The relevant legislation and regulations of Medicaid and TennCare clearly establish TennCare may deny coverage for services that are not medically necessary," and the ALJ's determination on this issue was supported by substantial and material evidence, the appeals court concluded. Accordingly, the appeals court affirmed the trial court's judgment.

Jones v. Bureau of TennCare, No. M2001-01065-COA-R3-CV, 2002 WL 1343223 (Tenn. Ct. App. June 20, 2002) (14 pages).

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