North Carolina



STATE OF NORTH CAROLINA IN THE OFFICE OF

ADMINISTRATIVE HEARINGS

COUNTY OF STANLY 07 INS 1511

|Elizabeth H Davis |) | |

|Petitioner |)) | |

| |) | |

|vs. |))))|DECISION |

| | | |

|State of North Carolina Teachers' | | |

|Healthcare Plan | | |

|Respondent | | |

On February 21, 2008, the undersigned conducted an administrative hearing in this matter in Charlotte, North Carolina. At the conclusion of the presentation of the evidence, the undersigned ruled that the Respondent correctly denied Petitioner’s request for approval of orthognathic surgery to correct a malocclusion for Petitioner’s 16-year-old daughter. On February 29, 2008, counsel for the Respondent forwarded a proposed Decision to the Office of Administrative Hearings, and the official record in this case is now closed.

APPEARANCES

For Petitioner: Elizabeth Davis, appearing Pro Se

29086 Jordans Pond Drive

Albemarle, North Carolina 28001

For Respondent: Robert D. Croom

Assistant Attorney General

North Carolina Department of Justice

Post Office Box 629

Raleigh, North Carolina 27602-0629

ISSUE

Whether the Respondent acted erroneously in denying Petitioner’s request for coverage of orthognathic surgery to correct a malocclusion for Petitioner’s 16-year-old daughter?

STATUTES AND POLICIES AT ISSUE

N.C. Gen. Stat. § 135-40.6 and North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan Medical Policy Number SU0410.

EXHIBITS ADMITTED INTO EVIDENCE

For Respondent: Exhibits 1, 2, 3, 4, 5, 5A, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16

For Petitioner: Exhibits 1, 2 and 3

FINDING OF FACTS

1. Respondent North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan (hereinafter “Respondent” or “Plan”) is an agency of the State of North Carolina that offers health care benefits to eligible active and retired employees and their enrolled dependents (collectively hereinafter “covered persons”) in accordance with the applicable N.C. General Statutes and the Plan’s medical policies. N.C. Gen. Stat. § 135-40 et seq. Plan benefits are administered by Blue Cross and Blue Shield of North Carolina, the Plan’s claims processing contractor.

2. Petitioner and her daughter are covered persons and are therefore entitled to Plan benefits.

3. On April 11, 2007, Petitioner, through a letter from Petitioner’s provider, Dr. Myron Tucker, D.D.S., made a request for prior approval of orthognathic surgery to correct a malocclusion for her 16-year-old daughter (hereinafter “Petitioner’s request”).

4. The letter from Dr. Tucker included office records from an April 11, 2007 visit and from a June 13, 2003 visit.

5. On April 19, 2007, the Plan denied Petitioner’s request.

6. On April 19, 2007, Dr. Tucker made a request by letter for a provider courtesy review of the denial decision.

7. No additional office records were included with Dr. Tucker’s April 19, 2007 letter.

8. On April 26, 2007, the Plan’s provider courtesy review upheld the original denial.

9. On April 27, 2007, Petitioner timely filed an internal grievance with the Plan challenging the Plan’s denial of Petitioner’s request.

10. In support of Petitioner’s grievance, Dr. Kenneth D. Owen submitted a letter with an office record from July 21, 2003, photographs of the daughter and photographs of the daughter’s teeth.

11. On May 25, 2007 the Plan denied Petitioner’s grievance.

12. Pursuant to N.C. Gen. Stat. § 58-50-75 et seq., Petitioner requested a Health Benefit Plan External Review of the grievance denial on June 14, 2007.

13. In support of her request for an external review, Petitioner submitted letters from Dr. Linda W. Lawrence and Dr. Margaret E. Lochary. No additional office records were submitted with the letters.

14. On July 24, 2007, the external reviewer upheld the Plan’s decision denying Petitioner’s request for approval.

15. On September 18, 2007, Petitioner timely filed her Petition herein.

Analysis

16. Pursuant to N.C. Gen. Stat. § 135-40.6(6)a, no benefits are provided for correction of malocclusions by orthognathic surgery or other procedures by repositioning of bone tissue except as permitted pursuant to N.C. Gen. Stat. § 135-40.6(5)c.

17. Pursuant to N.C. Gen. Stat. § 135-40.6(5)c, developmental and congenital orthognathic surgery procedures will be covered under the plan provided such surgery is medically necessary, is the only method of treatment which will correct the patient’s deformity, is not performed for cosmetic reasons, and is approved in advance by the Claims Processor based on the surgeon’s documentation showing that correction of the deformity is medically necessary for the maintenance of the patient’s good physical health.

18. The Plan has developed and follows North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan Medical Policy Number SU0410 (hereinafter “Policy SU0410") to determine when, under N.C. Gen. Stat. § 135-40.6, orthognathic surgery is considered to be medically necessary and eligible for coverage.

19. Policy SU0410 considers orthognathic surgery medically necessary and eligible for coverage if it is the only method that will correct the deformity, is not being done for cosmetic reasons and is for one or more of the reasons enumerated in the policy with medical record documentation from evaluating and treating providers demonstrating that required criteria relating to a listed condition have been fulfilled.

20. Policy SU0410 lists approval procedures which include, among other requirements, documentation of reasons for the surgery, substantiated by copies of the patient’s records to include history, examination, and prior non-surgical treatment; medical records from the oral/maxillofacial surgeon and from all other providers who have previously evaluated and treated the patient for malocclusion and any associated medical problems must be submitted for review.

21. The medical records submitted in support of Petitioner’s request do not demonstrate that the required criteria relating to any of the conditions listed in Policy SU0410 have been fulfilled.

CONCLUSIONS OF LAW

1. The Office of Administrative Hearings has jurisdiction to hear this matter.

2. The Plan is a creature of statute and is therefore governed by the applicable North Carolina General statutes and the medical policies adopted in accordance therewith.

3. The Plan followed proper procedure in reviewing Petitioner’s request.

4. Petitioner request must document the reasons for the surgery must be substantiated by copies of the patient’s records to include history, examination, and prior non-surgical treatment; medical records from the oral/maxillofacial surgeon and from all other providers who have previously evaluated and treated the member for malocclusion and any associated medical problems must be submitted for review.

5. The records submitted by Petitioner to the Plan fail to substantiate the reasons for the surgery or the presence of the required symptoms listed by Policy SU0410.

6. Based on the limited records provided to the Plan by Petitioner, the Plan acted correctly when it denied Petitioner’s request for approval.

DECISION

Based on the foregoing Findings of Facts and conclusions of law, it is hereby recommended that the decision of the Respondent to deny Petitioner’s grievance related to the Plan’s denial of Petitioner’s request for approval of orthognathic surgery to correct a malocclusion for her 16-year-old daughter be AFFIRMED.

NOTICE AND ORDER

The agency that will make the final decision in this contested case is the Board of trustees of the North Carolina Teachers’ and State employees’ Comprehensive Major Medical Plan (hereinafter “Agency”). The Agency is required to give each party an opportunity to file exceptions to and written arguments concerning this Recommended Decision. The Agency is further required to serve a copy of the Final Agency Decision on all Parties or their attorneys of record and on the Office of Administrative Hearings.

It is further ordered that if this matter is appealed to the Superior Court Division of the General Court of Justice, the exhibits and transcript are to be redacted to show the name of Petitioner’s daughter to be “JD” and the photographs of Petitioner’s daughter introduced as exhibits are to be sealed.

This the 11th day of March, 2008.

___________________________________

Shannon R. Joseph

Administrative Law Judge

APPEAL RIGHTS: Pursuant to Article 4 of Chapter 150B of the General Statutes of North Carolina, a party may appeal a Final Decision within 30 days after being served with a written copy of the decision by filing a Petition for judicial review in the Superior Court of Wake County or in the Superior Court of the county where the person appealing resides.

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