Massachusetts Court of Appeals Rules MassHealth Must Review Payment Denial for Teenager’s HIV-Related Surgery

A three-judge panel of the Massachusetts Court of Appeals on Tuesday ruled that MassHealth, the state's Medicaid provider, must review its decision to deny a claim filed in 2004 on behalf on a 15-year-old HIV-positive girl who underwent surgery to remove a growth on her neck caused by antiretroviral drugs, the Boston Globe reports (Ellement, Boston Globe, 2/20).

MassHealth denied authorization for the procedure shortly before it was performed on the girl, Ashley Shaw, even though her doctors said the procedure was medically necessary. According to the AP/Worcester Telegram, the growth caused abnormal posture, difficulty swallowing, back and neck pain, headaches and an inability to sleep without medication. Shaw's, mother Elizabeth Shaw, decided to proceed with the operation and appealed the denial to MassHealth. MassHealth in a hearing later said the procedure was not a "covered procedure," did not "meet medical necessity criteria" and was denied because it was a "(r)etroactive (r)equest."

The court in its ruling said Elizabeth Shaw had no choice but to proceed with the operation after MassHealth's initial denial because "no timely and reasonable alternative" was available. The court also said the case could not be considered retroactive because the initial request was made prior to the procedure and a decision was pending (LeBlanc, AP/Worcester Telegram, 2/19).

In addition, the court said the main issue in the case was not the time the request was made but whether the procedure was medically necessary and ordered MassHealth to decide the case on those grounds. Judge Elspeth Cypher in the opinion said the panel rejects MassHealth's "view that the review of Ashley's claim may be terminated because the procedure had been performed without authorization."

Jennifer Kritz, a spokesperson in Massachusetts' Executive Office of Health and Human Services, said MassHealth is reviewing the ruling and declined to comment further (Boston Globe, 2/20). Janson Wu -- an attorney with Gay & Lesbian Advocates & Defenders, which argued the case on behalf of the Shaws -- said the ruling is the "first time" a Massachusetts court "has ruled that MassHealth is misapplying their prior authorization regulation in this way," adding that the agency "ignore[d] the purpose" of the regulation in denying the original request (AP/Worcester Telegram, 2/19).