Texas Health and Human Services Commission v. Linda Puglisi
03-15-00226-CV
| Tex. App. | Aug 19, 2015Background
- This appeal is in the Third Court of Appeals, Austin, Texas, involving HHSC as Appellant and Linda Puglisi as Appellee.
- The dispute arises from Medicaid prior authorization denial for a medically necessary power wheelchair with an integrated standing feature.
- Linda sought Medicaid prior authorization for the wheelchair; Molina Healthcare denied, and the trial court reversed.
- HHSC claimed the integrated standing feature did not meet its definition of covered DME and challenged the medical necessity.
- The record centers on Medicaid’s prior-authorization standards, medical evidence of need, and whether due process was violated.
- The court’s analysis emphasizes the adequacy of medical evidence and the proper application of Medicaid’s coverage definitions.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Is the integrated standing feature covered DME under HHSC’s definition? | Puglisi: feature meets DME definition and state law. | HHSC: feature not covered DME. | Yes; court reversal favored Linda on coverage. |
| Does Linda’s medical need justify the wheelchair despite disability severity? | Puglisi: need persists; severity not a bar. | HHSC: severity undermines need. | Yes; medical necessity not diminished by disability severity. |
| Do state payment/order-of-payment rules control Medicaid prior authorization here? | Puglisi: case involves prior authorization, not payment sequencing. | HHSC: related provisions govern dual-eligible payments. | Not controlling for prior authorization issue. |
| Is HHSC’s hearing decision supported by substantial evidence? | Puglisi: agency failed to apply medical-necessity standards; evidence lacking. | HHSC: findings sufficient. | No; decision unsupported by substantial medical evidence. |
| Do Detgen or DeSario support HHSC’s decision? | Puglisi: Detgen/DeSario do not mandate denial here. | HHSC: relies on those authorities. | No; not controlling; record shows error in application. |
Key Cases Cited
- DeSario v. Thomas, 139 F.3d 80 (2d Cir. 1998) (relevance to DME coverage debates (Supreme Court vacated))
- Detgen v. Janek, 945 F. Supp. 2d 746 (N.D. Tex. 2013) (discussed in DME coverage context)
- Lankford v. Sherman, 451 F.3d 496 (8th Cir. 2006) (equal-access/comparability in Medicaid coverage)