Ronald Fournier v. Kathleen Sebelius
2013 U.S. App. LEXIS 10997
| 9th Cir. | 2013Background
- Berg and DiCecco are Medicare beneficiaries who received outpatient dental procedures tied to Sjogren’s syndrome and graft-versus-host disease, respectively, and their claims were denied under the dental exclusion.
- The dental exclusion in §1395y(a)(12) broadly bars payment for services in connection with care of teeth, with limited inpatient exceptions and a same-physician rule.
- The district court upheld the Secretary’s interpretation of the exclusion as reasonable and denied equal-protection challenges.
- Appellants seek coverage for extensive dental work as medically necessary but argue the Secretary’s policy is irrational and contrary to Congress’s intent to cover complex surgical procedures.
- The court analyzes whether the statutory exclusion is ambiguous and, if so, whether the Secretary’s interpretation is reasonable and entitled to Chevron deference.
- The majority ultimately affirms, holding the statute is ambiguous, Chevron deference applies, the Secretary’s interpretation is reasonable, and the equal-protection claim fails.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether §1395y(a)(12) is ambiguous as applied to outpatient dental services. | Berg and DiCecco argue ambiguity allows broader coverage. | Secretary contends exclusion unambiguously bars outpatient dental services. | Statute ambiguous; Chevron applies. |
| Whether the Secretary’s interpretation of the dental exclusion is reasonable. | Chevron deference should not apply or the interpretation is unreasonable. | Interpretation fills interstices and is reasonable. | Secretary’s interpretation is reasonable and permissible. |
| Whether the policy violatesthe Fifth Amendment equal protection. | Classification irrational; favors some dental cases over others. | Classification rationally related to limiting coverage and managing resources. | No equal-protection violation. |
Key Cases Cited
- Barnhart v. Walton, 535 U.S. 212 (2002) (Mead factors; deference to agency interpretations)
- Mead Corp. v. Dept. of the Army, 533 U.S. 218 (2001) (framework for Chevron deference when agency interpretations carry force of law)
- Good Samaritan Hosp. v. Shalala, 508 U.S. 402 (1993) (longstanding interpretations merit deference)