United States District Court, D. Colorado
RAYMOND P. MOORE UNITED STATES DISTRICT JUDGE.
Julia Anne Maslanik (Plaintiff) brings this matter before the court seeking judicial review of a decision by the Secretary of the U.S. Department of Health and Human Services (Secretary) denying Plaintiff’s requested reimbursement for dental services she received from various providers in 2010. (ECF No.1). Plaintiff, an enrollee in Kaiser’s Senior Advantage Health Maintenance Organization (HMO), a Medicare Advantage plan (MA), incurred the contested expenses for dental services to remediate, repair and replace the damage to her teeth and their supporting structures that Plaintiff sustained when she fell while suffering a grand mal seizure on December 30, 2009. (ECF Nos. 15, p.7; 16, p.7).
II PROCEDURAL HISTORY
This case has a protracted procedural history which began in late December, 2010, when Kaiser Foundation Health Plan of Colorado (Kaiser) denied Plaintiff’s requested reimbursement for dental services that she had received from January through November of 2010. (ECF No.12, pp.175-186). Plaintiff requested reconsideration of Kaiser’s denial on April 30, 2011. (ECF No.12, p.196). Kaiser affirmed its original denial on June 3, 2011. (ECF No. 12, p.173). The next day, Kaiser sent Plaintiff’s file to Maximus Federal Services, an independent review entity. (ECRF No.12, pp.201-203). After consideration, Maximus affirmed Kaiser’s decision on June 29, 2011. (ECF No. 12, pp.170-71).
Plaintiff requested a hearing before an Administrative Law Judge (ALJ) on July 6, 2011. (ECF No. 12, p.127). An ALJ conducted a telephone hearing on November 17, 2011. (ECF No. 12, pp.223-60). At the hearing Plaintiff presented testimony, was represented by counsel and accompanied by her family members, some of whom also testified. (ECF No.12, pp.225-28). An Appeals Analyst and the Chief of Appeals and Risk Management for Kaiser in Colorado represented Kaiser. (ECF No. 12, p.229). The ALJ issued a favorable decision for Plaintiff on February 21, 2012, finding that Kaiser’s coverage extended beyond the requirements of Medicare. The ALJ therefore ordered Kaiser to reimburse Plaintiff for her dental expenses. (ECF No.12, pp.40-48). Kaiser sought review of the ALJ’s decision by the Medicare Appeals Council (Council) on April 18, 2012. (ECF No. 12, pp.29-37).
The Council reversed the ALJ’s decision finding “that the MA plan at issue does not provide dental benefits beyond the parameters of coverage in accordance with original Medicare requirements for dental services. The Medical Advantage Organization (MAO) is not required to cover or reimburse the enrollee for, the dental services the enrollee received on various dates in 2010.” (ECF No. 12, pp.1-14). Plaintiff now seeks federal court review of that final decision pursuant to 42 U.S.C. § 1395w-22(g)(5). (ECF No.1, p.3).
III ADMINISTRATIVE LAW JUDGE’S DECISION
The ALJ noted that Medicare does not generally cover dental services unless the beneficiary’s situation falls under an exception. (ECF No. 12, p.46). The ALJ noted that Medicare does not cover services in connection with the care, treatment, filling, removal or replacement of teeth, or structures directly supporting the teeth. (ECF No. 12, p.47)(emphasis in original). The ALJ found that the dental services received by the Plaintiff did not fall under the limited exceptions to the dental service exclusion and she therefore did not qualify for coverage under Medicare. (ECF No. 12, p.47).
However, the ALJ noted that although page 35 of the Kaiser Evidence of Coverage stated that it covered items and services in accordance with Medicare Rules, Kaiser’s coverage did provide coverage for dental services above and beyond what is covered by Medicare. (ECF No.12, p.47). As a result, the ALJ found Kaiser’s terms regarding dental coverage were vague and ambiguous. Id. He therefore construed the Evidence of Coverage (EOC) terms against Kaiser, the drafting party. (ECF No.12, pp.47-48).
Because Plaintiff received her dental services as a direct consequence of experiencing a seizure, the ALJ found that her dental services “hardly fall within the common understanding of the word routine.” (ECF No.12, p.48). Although Plaintiff did not receive her dental services from a hospital or a network provider, the ALJ found that “inconsequential” because Kaiser does provide that “cosmetic surgery or procedures are covered if they are needed as a result of accidental injury or to correct disfigurement resulting from an injury . . . .” Id. The ALJ therefore ordered Kaiser to reimburse Plaintiff for the dental services she received from various dentists in 2010. Id.
IV. MEDICARE APPEALS COUNCIL DECISION
The Council noted that as the authorities provided and the ALJ’s decision acknowledged, Medicare generally does not cover dental services. (ECF No.12, p.9). The record before the Council contained evidence submitted by the treating dentists indicating that the services provided were “dental” and provided “in connection with the care, treatment, filing, removal or replacement of teeth or structures directly supporting teeth.” Id. Kaiser also argued that the services in question were dental services and the Council noted that Plaintiff did not dispute that point. Id.
The Council found that Plaintiff’s dental procedures were not performed in an inpatient setting and so were not hospital related costs. Id. The Council noted that the services provided were not part of other covered procedures, did not encompass specific exceptions that would implicate Kaiser coverage, or ...