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Carroll v. Iowa Department of Human Services

Court of Appeals of Iowa

June 19, 2019

WILLIE CARROLL, Plaintiff-Appellant/Cross-Appellee,
v.
IOWA DEPARTMENT OF HUMAN SERVICES, Defendant-Appellee/Cross-Appellant.

          Appeal from the Iowa District Court for Polk County, Lawrence P. McLellan, Judge.

         Willie Carroll appeals, and the Iowa Department of Human Services cross-appeals, a district court ruling on Carroll's petition for judicial review partially affirming an agency determination and remanding the matter to the agency.

          Judith R. Bӧes, Sarah K. Franklin, and Abhay M. Nadipuram of Davis, Brown, Koehn, Shors & Roberts, P.C., Des Moines, for appellant.

          Thomas J. Miller, Attorney General, and Lisa Reel Schmidt, Assistant Attorney General, for appellee.

          Considered by Doyle, P.J., Mullins, J., and Mahan, S.J. [*]

          MULLINS, JUDGE.

         Willie Carroll appeals, and the Iowa Department of Human Services (DHS) cross-appeals, a district court ruling on Carroll's petition for judicial review partially affirming an agency determination and remanding the matter to the agency.

         Carroll argues the district court erred in affirming the denial of four out of five of the skilled-nursing visits she requested to be covered by her managed-care organization because (1) the court failed "to consider whether the requested skilled nursing visits qualify as 'restorative and maintenance home health agency services'" under Iowa Administrative Code rule 441-78.9, (2) DHS abused its discretion in using arbitrary criteria in denying the request, (3) the court erred in failing to find DHS's decision's negative impact on private rights is grossly disproportionate to the public interest, and (4) the factual determinations that skilled-nursing visits were not medically necessary are unsupported by substantial evidence.[1]

         On cross-appeal, DHS contends the district court erred in remanding the matter to the agency for the purpose of determining whether one of the five requested skilled-nursing visits was medically necessary. Specifically, DHS argues the agency determination that all five requested visits were not medically necessary is supported by substantial evidence.

          I. Background Facts and Proceedings

         Carroll is a Medicaid recipient. She has been diagnosed with type-2 diabetes and suffers from other medical conditions. She has previously utilized in-home, skilled-nursing services. There is evidence that Carroll's diabetes has been poorly managed in the past, and Carroll has been forgetful about checking her blood-sugar levels at times. To remedy this situation, Carroll utilizes a telehealth service that calls to remind her to check and record her blood sugar. These figures are then relayed to Carroll's physician.

         On January 9, 2017, Carroll's home-health provider, Iowa Home Care (IHC), submitted to Amerigroup, a managed-care organization, a request for prior authorization for Carroll to receive nine in-home, skilled-nursing visits between January 30 and March 30, 2017. Accompanying the request was a plan of care contemplating specific skilled-nursing services and a sixty-day summary dated November 28, 2016. The summary noted that in the past sixty days, Carroll had not suffered any falls, injuries, or hospitalizations; she properly managed all of her medications on her own; she attended all of her medical appointments; she was able to "perform all personal cares"; her blood sugar was consistent; she performed foot care on her own; and she experienced no issues relative to esophageal obstruction, diverticulitis, anxiety, or hypertension. Amerigroup denied the request, determining the requested skilled-nursing services were not medically necessary. This determination was not appealed.

         On February 2, IHC submitted to Amerigroup a second request for prior authorization for Carroll to receive five skilled-nursing visits during the same period. This request included an addendum stating Carroll "requires monitoring for diabetic management, testing and diet compliance with education. 1 visit for recertification is included in the total of 5 visits requested." The plan of care requested that a skilled nurse "observe and assess" Carroll, perform specific tasks, and provide her with education.[2] The request also included a care plan visit summary review report, dated January 26, 2017. The report noted Carroll was "alert and oriented x3" and she generally was not experiencing any physical or medical issues; the authoring nurse noted she had "no concerns" for Carroll's condition. On February 10, following a physician review, Amerigroup denied the request, again concluding the requested services were not medically necessary.

         In March, Carroll and IHC filed an internal appeal with Amerigroup.[3] An external review was conducted by Dr. Lawrence Koss, who determined the denial was appropriate, concluding the "requested skilled nursing visits are not medically necessary." Specifically, Koss concluded the requested services could be safely performed by Carroll or other non-skilled person with proper training, and it was not medically necessary that they be performed by a nurse. Amerigroup informed Carroll and IHC it would be upholding its denial of coverage and the decision was final.

         In April, Carroll and IHC filed an appeal and request for hearing with DHS. Prior to hearing, Carroll submitted additional documentation.[4] In light of the additional documentation, Amerigroup submitted the matter to a second external reviewer, Dr. Sohail Saeed, who likewise concluded the requested services were not medically necessary. Specifically, Saeed determined the requested services did not require the utilization of a skilled nurse. A hearing was held in May, after which an administrative law judge (ALJ) entered a proposed decision affirming Amerigroup's denial of coverage, also concluding the requested services were not medically necessary. Carroll filed a request for review with DHS. Following a review, the director of DHS adopted the ALJ's proposed decision as the final decision.

         In July, Carroll filed a petition for judicial review in the district court. She amended her petition in August. Following a hearing, the district court affirmed the denial of four out of the five requested visits. The court remanded the matter to the agency to consider whether the skilled-nursing visit Carroll received on February 21 was medically necessary. As noted, both parties appeal.

         II. Standard of Review

         "Judicial review of agency decisions is governed by Iowa Code section 17A.19." Brakke v. Iowa Dep't of Nat. Res., 897 N.W.2d 522, 530 (Iowa 2017) (quoting Kay-Decker v. Iowa State Bd. of Tax Review, 857 N.W.2d 216, 222 (Iowa 2014)); accord Warren Props. v. Stewart, 864 N.W.2d 307, 311 (Iowa 2015). The district court acts in an appellate capacity in judicial-review proceedings. Iowa Med. Soc'y v. Iowa Bd. of Nursing, 831 N.W.2d 826, 838 (Iowa 2013) (quoting City of Sioux City v. GME, Ltd., 584 N.W.2d 322, 324 (Iowa 1998)). On appeal, this court "appl[ies] the standards of section 17A.19(10) to determine if we reach the same results as the district court." Brakke, 897 N.W.2d at 530 (quoting Renda v. Iowa Civil Rights Comm'n, 784 N.W.2d 8, 10 (Iowa 2010)); accord Des Moines Area Transit Auth. v. Young, 867 N.W.2d 839, 842 (Iowa 2015). Relief in a judicial-review proceeding is appropriate only "if the agency action prejudiced the substantial rights of the petitioner and if the agency action falls within one of the criteria listed in section 17A.19(10)(a) though (n)." Brakke, 897 N.W.2d at 530.

         III. ...


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