Fournier v. Sebelius
839 F. Supp. 2d 1077
D. Ariz.2012Background
- Plaintiffs seek Medicare coverage for dental services to repair or extract teeth damaged by loss of salivary function due to medical conditions and treatment.
- Fournier received a favorable ALJ decision on November 1, 2009, making his claim moot in this appeal.
- Berg and DiCecco challenges involve claims denied under the broad dental exclusion in 42 U.S.C. § 1395y(a)(12) and MAC determinations.
- Berg’s MA plan denied abutments and a partial denture; the ALJ and MAC upheld denial as the dental work falls within the exclusion.
- DiCecco sought crowns and resins under Part B; the MAC denied coverage since the services were not performed as an incident to a covered procedure on the same occasion.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Berg and DiCecco’s dental services are covered despite the dental exclusion. | Berg and DiCecco contend exceptions apply due to underlying medical conditions. | Services are excluded unless an explicit exception applies or performed incident to a covered procedure. | Denials affirmed; services fall under the exclusion. |
| Whether Fournier’s approval renders his claim moot. | Fournier's prior favorable decision does not affect Berg/DiCecco claims. | Fournier’s coverage grants mootness for this appeal. | Fournier’s claim is moot; Berg and DiCecco remain denied. |
| Whether the Secretary’s interpretation of the dental exclusion is reasonable and consistent with Congress’s intent. | Statutory history supports broader coverage for nonroutine, medically necessary dental work. | statute and regulations limit dental coverage; exclusions apply regardless of complexity. | Secretary’s interpretation upheld; reasonable and consistent. |
| Whether the claims can be pursued as a nationwide class action under 42 U.S.C. § 405(g). | Plaintiffs seek class-wide relief for denied extraordinary dental services. | Exhaustion and presentment requirements prohibit class treatment here. | Class action relief denied; individual claims required. |
| Whether equal protection requires a different treatment of dental exclusions. | Policy distinctions between covered and noncovered services lack rational basis. | Congress rationally limited dental coverage; equal protection not violated. | Rational basis review upheld; no equal protection violation. |
Key Cases Cited
- Wood v. Thompson, 246 F.3d 1026 (7th Cir.2001) (court defers to Congress on dental exclusion while noting limited exceptions)
- Goodman v. Sullivan, 891 F.2d 449 (2d Cir.1989) (Medicare exclusion of dental services acknowledged)
- Schweiker v. Wilson, 450 U.S. 221 (1981) (equal protection rational basis review standard in social welfare cases)
- Bass v. SSA, 872 F.2d 832 (9th Cir.1989) (collateral nature of claims for exhaustion viability)
- Maggio v. Shalala, 40 F.Supp.2d 137 (W.D.N.Y.1999) (illustrates treatment of underlying medical conditions with dental procedures)