Opinion
In this сase we conclude the state Department of Health Services (Department) wrongly excluded stairway chair lifts from the scope *983 of health coverage for the medically indigent, under the terms of the California Medical Assistance (Medi-Cal) program, Welfare and Institutions Code section 14000 et seq.
Appellants Vera Blue (Blue) and two nonprofit organizations, the Center for Independent Living (CIL) and the Independent Living Resource Center (ILRC), brought a petition for writ of mandate, in which appellants sought to compel respondent Dirеctor of the Department to pay for the costs of providing stairway chair lifts to certain medically indigent and disabled persons covered by the Medi-Cal program. The superior court initially ruled that a stairway chair lift was a covered Medi-Cal benefit, and that Blue was entitled to relief. However, after the Department amended its regulations to " specifically exclude such coverage, the court ruled that other medically indigent patients were not generally entitled to this coverage.
We hold that the Department could not exclude such coverage by its new regulation, and we therefore reverse the ultimate legal ruling of the trial court.
I. Facts and Procedural History
The relevant facts are not in dispute. Blue is covered by the Medi-Cal health benefits program for the medically indigent. She suffers from osteoarthritis and other health conditions, which make it difficult or impossible for her to ascend and descend stairs without assistance, although she can walk on a level surface by using her walker. She has resided for many years in her daughter’s home, which is a split-level structure in which the kitchen and mаin living areas are on the lower floor, while the bedrooms and only bathroom are on the upper floor. Blue’s daughter worked full-time outside the home, and was not able to assist her mother up and down the stairs during the workday. In June 1997, Blue fell while attempting to climb the stairs, and broke her collar bone. After that fall, she had to spend her days on the upper floor, and was generally unable to cook or leave the home in the event of a daytime emergency.
On August 18, 1997, Blue’s health care provider, Western Rehab Systems, filed a treatment authorization request (TAR) with the Department, seeking to obtain financial resources for the purchase of an Access Stairway Lift. This item of machinery, also called a stair lift, motorized stair lift, stair glide, or stair glider, is a mechanized chair apparatus running on a track or rail along the stairs. The stair lift can be installed and removed relatively easily, and is specifically designed to help patients go up and down stairs. The TAR was accompanied by a letter from Blue’s physician, explaining the *984 need for such a stair lift to safely carry Blue up and down the stairs and avoid another injury, or the need to place her in an assisted living environment such as a nursing home.
On August 22, 1997, a Medi-Cal consultant acting for the Department denied the TAR for the stair lift, stating that the stair lift was not an authorized Medi-Cal benefit. Blue’s provider then filed an initial administrative appeal. The initial appeal was denied by a director in a Medi-Cal field office on October 28, 1997, on the grounds that such a stair lift was not covered by Medi-Cal, because it would constitute an alteration or improvement to real property, which is not gеnerally covered.
Blue requested a hearing before an administrative law judge (ALJ). The ALJ ruled in her favor, finding that the stair lift was not a fixture added to real property, since it could be installed and removed. The ALJ analogized the stair lift to a wheelchair, which is a covered benefit under Medi-Cal as a necessary means of allowing a person to safely move about the home. According to the ALJ’s opinion, Medi-Cal was required to cover the expense of the stair lift because it qualified as “durable medical equipment.”
The directоr exercised her discretion to overrule the ALJ’s decision, and she issued a “Director’s Alternate Decision” ruling against Blue. The director’s decision found the stair lift constituted a modification or alteration to real property. 1 In addition, even if such a stair lift did not constitute a modification to real property because it could be easily removed, the director concluded that the stair lift also did not qualify for coverage as it was not used primarily for health care, and thus was not a covered Medi-Cal benefit.
Blue next filed a рetition for writ of mandate in the superior court, in which she sought to challenge the director’s administrative decision as to herself and all other “similarly situated recipients.” The two nonprofit organizations, CIL and ILRC, also appeared as petitioners who were seeking relief for their respective members.
The superior court initially granted the petition as to Blue, and issued a peremptory writ of mandate directing the Department to provide payment for her stair lift, because the stair lift constituted durable medical equipmеnt. The Department agreed to stipulate to pay for Blue’s stair lift, in obedience to the trial court’s issuance of the writ. Similar relief was at first denied as to all other persons, as insufficient evidence had been adduced as to the needs of any other persons.
*985 Blue and the two nonprofit organizations then moved to file an amended and supplemental petition. The declaration supporting the motion advised that the Department had recently promulgated a new “emergency” regulation, which we discuss in more detail in рart II of this opinion, specifically stating that stairway chair lifts would not be covered by Medi-Cal in the future. It therefore became necessary to file an amended petition to challenge the validity of the Department’s new regulation barring Medi-Cal coverage of stairway chair lifts. Appellants’ motion to file the amended petition was granted.
Following a hearing on the amended petition, the trial court upheld the validity of the Department’s new regulation disallowing coverage of stairway chair lifts. In particular, the court rulеd that the Department did not abuse its legal discretion in promulgating the new regulation. A judgment denying the petition was entered, and this appeal followed.
II. Discussion
A. Standard of Review
This appeal raises only issues of law, on a record of undisputed facts. We therefore exercise de novo or independent review.
(Ghirardo v. Antonioli
(1994)
B. Medi-Cal, Medicaid, and the Definition of “Durable Medical Equipment”
1. Medi-Cal and Medicaid
The state Medi-Cal program implements the federal Medicaid program, established under title XIX of the Social Security Act (42 U.S.C. § 1396 et seq.) (the Medicaid Act), which authorizes the payment of federal funds to states to defray the cost of providing mеdical assistance to low-income persons.
(Robert F. Kennedy Medical Center v. Belshé
(1996)
Although California has some latitude in designing its state program, it may not unreasonably or arbitrarily reduce the scope of coverage for a required service so as to discriminate against a specific medical condition or
*986
deny necessary medical coverage. (See
Beal
v.
Doe
(1977)
A health care provider obtains prior approval of services for a Medi-Cal patient by submitting a TAR to a consultant in the local Medi-Cal field office, as occurred in this case. (Cal. Code Regs., tit. 22, § 51003.) The consultant first determines whether the proposed services are medically necessary. If services are approved, the health care provider then receives an approved copy of the TAR. If the TAR is not approved, the matter is subject to administrative review and ultimately judicial review, аs we must undertake here. (See ibid.)
2. The Scope of Medi-Cal Coverage for “Durable Medical Equipment”
Title XIX of the Medicaid Act (42 U.S.C. § 1396 et seq.) provides that if a state seeks to cover “home health care services” for the medically indigent, then the state must also provide benefits for “durable medical equipment.” (42 U.S.C. §§ 1396d(a)(7), 1395x(m)(5).) Oddly enough, neither the Medicaid Act itself, nor its accompanying Medicaid regulations, specifically define the critical term “durable medical equipment,” although a nonexclusive statutory list of representative mеdical equipment includes “iron lungs, oxygen tents, hospital beds, and wheelchairs.” (42 U.S.C. § 1395x(n).) It is left to the states to define the term “durable medical equipment” (sometimes abbreviated as DME) by setting reasonable state standards for coverage. (See generally Comment, Medicaid and Durable Medical Equipment: An Ongoing Battle Between Expense and Health (2000) 59 Md. L.Rev. 669.)
California has defined this term, as have many other states, by adopting the definition of “durable medical equipment” from federal regulations governing a different but related federal program, the Medicаre program for the elderly. The federal Medicare regulatory definition for “durable medical equipment” is: “equipment, furnished by a supplier or a home health agency, that—HQ (1) Can withstand repeated use; HQ (2) Is primarily and customarily used to serve a medical purpose; HQ (3) Generally is not useful to an *987 individual in the absence of an illness or injury; and HQ (4) Is appropriate for use in the home.” (42 C.F.R. § 414.202 (2001).)
California requires by statute that “[djurable medical equipment,” be covered by the California Medi-Cal program. (Welf. & Inst. Code, § 14132, subd. (m).) California has also generally dеfined this term by a long-standing state regulation, based on the federal Medicare regulation, which reads: “Durable medical equipment means equipment prescribed by a licensed practitioner to meet medical equipment needs of the patient that: [IQ (a) Can withstand repeated use. HO (b) Is used to serve a medical purpose. HD (c) Is not useful to an individual in the absence .of an illness, injury, functional impairment, or congenital anomaly. HQ (d) Is appropriate for use in or out of the patient’s home.” (Cal. Code Regs., tit. 22, §51160.) The trial court initially held that stairway chair lifts met this definition of durable medical equipment.
3. The Department’s New “Emergency” Regulation Relating to Stairway Chair Lifts
After the trial court ruled that stairway chair lifts met the definition of durable medical equipment set forth above, the Department promulgated a new “emergency” regulation (which has since become permanent) amending the basic definition of durable medical equipment in California Code of Regulations, title 22, section 51160. This new regulation reads, in pertinent part: “(e) The following items are not covered by the program: HQ ... HQ (11) Stairway chairlifts, or other devices which are temporarily or permanently affixed to, or installed in, any part of a home, for the purpose of transporting persons between floors. For the purpose of this section ‘stairway chairlift’ means a chair assembly which moves on a track mounted to a staircase, which connects two floors of a structure.” (Cal. Code Regs., tit. 22, § 51321.)
C. The Department’s Exclusion of Stairway Chair Lifts from the Scope of Medi-Cal Coverage as “Durable Medical Equipment”
As we have mentioned, ante, before the Department’s enactment of its new exclusionary regulation, the trial court initially found that stairway chair lifts met the general definition of “durable medical equipment” for purposes of this statute requiring coverage, and the regulations existing at the time Blue first sought coverage. The Department concedes that stairway chair lifts are “durable” and constitute “equipment,” but contests whether such lifts serve a “medical” purpose.
The parties have not cited, and our own research has not disclosed, any relevant precedents from Californiа or other states specifically addressing *988 the question of whether a stairway chair lift constitutes “durable medical equipment.” In the absence of relevant legal precedents, we must address this issue of law by reference to the wording of the Medicaid Act itself, together with the California statutes and regulations on point, which define durable medical equipment.
“The words of the statute are the starting point. ‘Words used in a statute should be given the meaning they bear in ordinary use. . . . If the language is clear and unambiguous there is no need for construction, nor is it necessary to resort to indicia of the intent of the Legislature. . . .’ . . .If the language permits more than one reasonable interpretation, however, the court looks ‘to a variety of extrinsic aids, including the ostensible objects to be achieved, the evils to be remedied, the legislative history, public policy, contemporaneous administrative construction, and the statutory scheme of which the statute is a part.’ . . . After considering these extrinsic aids, we ‘must select the construction that comports most closely with the aрparent intent of the Legislature, with a view to promoting rather than defeating the general purpose of the statute, and avoid an interpretation that would lead to absurd consequences.’ ”
(Wilcox
v.
Birtwhistle
(1999)
1. “The words of the statute are the starting point.”
Beginning with the language of the relevant statutes, the Medicaid Act and the statutes defining California’s Medi-Cal program, it is apparent that states must provide coverage for “durable medical equipment,” which includes a stairway chair lift, for the reasons that follow.
Initially, we note that the Medicaid Act mandates that states such as California whiсh elect to provide home health services must provide coverage for “durable medical equipment.” (42 U.S.C. § 1395x(m)(5).) This term is not defined by statute, although a nonexclusive statutory list of representative medical equipment includes “iron lungs, oxygen tents, hospital beds, and wheelchairs.” (42 U.S.C. § 1395x(n).)
California echoes this federal mandate, requiring that “[djurable medical equipment” be covered by the California Medi-Cal program. (Welf. & Inst. Code, § 14132, subd. (m).) Although California has also not defined that term by statute, it previously adopted long-standing regulations defining “durable medical еquipment” as applying to equipment that “(a) Can withstand repeated use. [^Q (b) Is used to serve a medical purpose. [^]] (c) Is not useful to an individual in the absence of an illness, injury, functional impairment, or congenital anomaly. HQ (d) Is appropriate for use in or out of the patient’s home.” (Cal. Code Regs., tit. 22, § 51160.)
*989 The language of the relevant statutes and applicable regulations thus discloses a clear intent to broadly cover all “durable medical equipment” without any expressed limitation.
2. “Words used in a statute should be given the meaning they bear in ordinary use”
The words of the relevant statutes also must be given the meaning they bear in ordinary use. In particular, the parties dispute the meaning of the term “medical” as used in the phrase “durable medical equipment.” The Department asserts that a stairway chair lift is not “medical” equipment, under the Department’s own specialized and restrictive meaning of that term, which is limited to equipment which cures a medical condition.
We however must give the word “medical” its ordinary sense, as referring more usually and broadly to the treatment, cure, оr alleviation of any health condition, including a disability such as the inability to climb stairs. In accord with this broader definition of the term “medical,” California has defined “medical necessity” in Welfare and Institutions Code section 14059.5, in the following manner: “A service is ‘medically necessary’ or a ‘medical necessity’ when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.” A stairway chair lift qualifies as “medical” equipment under this definition because it prevents significant disability, аnd is reasonable and necessary to protect life or prevent injury such as the injury Blue suffered while attempting to use the stairs without a chair lift.
The nonexclusive list of items constituting durable medical equipment, such as wheelchairs and iron lungs, is also consistent with such a broad definition of the statutory term “medical,” and requires similar coverage for stairway chair lifts that are prescribed to alleviate medical conditions. Equipment such as iron lungs and wheelchairs would not cure the underlying medical condition, but would help to alleviate the effects of the medical condition by restoring necessary human functions such as respiration or the ability to move about. Similarly, a stairway chair lift alleviates a medical condition such as osteoarthritis by restoring the ability to move about the different levels of a home, where this is medically necessary for a patient.
3. “Extrinsic aids, including the ostensible objects to be achieved, and the evils to be remedied.”
We could also reach a similar result by another process of statutory interpretation. Under the principle of statutory intеrpretation
*990
known as
noscitur a sociis
(the term may be defined by reference to its fellow members of a class), we note that the list of representative medical equipment includes items that are medically necessary, and are not commonly used by persons except those suffering from a disabling medical condition. An obvious purpose of the home health care coverage for durable medical equipment is to permit indigent patients who are affected by medical problems to continue to live at home, rather than in an institution.
(Granato
v.
Bane
(2d Cir. 1996)
As in the case of a wheelchair, a stairway chair lift restores mobility lost as a result of a medical condition or disability, enabling the patient to reside at home rather than in an institution. And, as in the case of appellant Blue, a patient uses such a lift to ascend or descend stairs when this is not otherwise possible for the patient due to a medical condition or disability. Persons who do not suffer from a disabling medical condition or injury, and are able to climb stairs on their own, therefore would not find installation of such a chair lift useful in negotiating stairways.
And finally, we point out that the evil to be remedied by the relevant Medicaid and Medi-Cal statutes is the denial of necessary medical equipment for use in home health care, leading to unnecessary disability or institutionalization. The Department may not unreasonably or arbitrarily reduce the scope of coverage for a required service so as to discriminate against a specific medical condition, such as osteoarthritis or other medical conditions preventing normal use of the stairs, nor may the Department deny necessary medical coverage for such conditions. (See
Beal, supra,
A stairway chair lift prescribed by a physician for a medical purpose meets the general definition of “durable medical equipment” because the lift: “(a) Can withstand repeated use. HD (b) Is used to serve a medical purpose. HQ (c) Is not useful to an individual in the absence of an illness, injury, functional impairment, or congenital anomaly. HQ (d) Is appropriate for use in or out of the patient’s home.” (Cal. Code Regs., tit. 22, § 51160.) And thus we conclude that a stairway chair lift qualifies as “durable medical equipment” by statute, as well as under the Department’s general regulatory definition.
D. The Department’s “Emergency” Regulation Excluding Chair Lifts
The Department maintains that its new “emergency” regulation excluding stairway chair lifts from Medi-Cal coverage should be followed by
*991
this court, since the Department has made an administrative determination under authority delegated to it by the Legislature. In the Department’s view, the scope of our review is quite narrow. We disagree. The question of whether stairway chair lifts constitute “durable medical equipment,” on the present undisputed facts, is a purely legal question, not calling for any factual inquiry or specialized administrative expertise. We are not bound by the Department’s determination on this issue of law.
(Halaco Engineering Co.
v.
South Central Coast Regional Com.
(1986)
On this issue of the interpretation of the Department’s Medi-Cal regulations we are also guided by authority from our own appellate district. In
Jackson v. Stockdale
(1989)
This court (Div. Five) cited and followed
Jackson
in another decision discussing the topic of Medi-Cal coverage for “durable medical equipment,” in
Ruth v. Kizer
(1992)
We reach a similar result in this case, concluding that a stairway chair lift does constitute durable medical equipment, which must be covered by statute, and which cannot be excluded by regulation. (See
Ruth, supra,
8 Cal.App.4th at pp. 386-390;
Jackson, supra,
E. The Department’s Other Arguments Are Without Merit
The Department contends our ruling will set off a parade of horribles, leading to mandated coverage of numerous outlandish items as “durable medical equipment,” such as an elevator, a dumbwaiter, a special large television for patients with poor eyesight, carpeting, or an electric toothbrush for one who has trouble brushing her teeth. However, the Department’s apparent fears in this respect are overstated. None of these items qualify as “durable medical equipment,” because they are all regularly and primarily used by persons who do not have a specific medical need for them.
Moreover, our ruling leaves considerable discretion in the hands of the Department to prevent abuses. The Department retains the discretion to restrict stair lift coverage to those Medi-Cal patients for whom it is actually medically necessary, and may subject this coverage to cost utilization controls, if other more economical means exist to remedy the problem. For instance, where a residence has its kitchen, main living area, a bathroom, and a room usable as a bedroom on the ground floor, the Department need not provide a stair lift for access to an upper floor, attic, or basement.
The Department claims that Blue and those like her, who live in two-story homes, have simply made a “lifestyle choice” to reside in such dwellings. However, the evidence shows that Blue has lived in her current residence for many years. She resides with her daughter, who provides necessary care аnd companionship. Her medical clinic, church, and friends are all close by. Blue can no longer live alone. The only choice Blue has, if she could not obtain a chair lift, would be to live in a nursing home. This alternative would be considerably more expensive for Medi-Cal, and would not be the preferred
*993
medical outcome for patients who are still capable of living independently with some minor assistance. Indeed, the very purpose of the home health care coverage for durable medical equipment is to allow the indigent who are afflicted with medical problems to continue to live at home, rather than in an institution. (See
Granato, supra,
We certainly agree that the Department need not provide coverage for stairway chair lifts if only a lifestyle choice is at stake. There is obviously no medical or financial necessity requiring the Department to provide stair lifts for spry millionaires who wish to visit the turret rooms of their mansions. Durable medical equipment should be provided only to the medically indigent who are found to have a valid medical neсessity requiring its use. By our ruling, we do not suggest that fiscal considerations are entirely irrelevant in deciding whether coverage for such equipment is to be afforded. Where it is possible, easy, and inexpensive for a patient to move to a one-story dwelling or a downstairs bedroom, that may well be the preferred alternative. However, the Department may not categorically exclude coverage for stairway chair lifts which are medically necessary.
Finally, we point out that our ruling is subject to legislative oversight. Congress or the Legislature may restrict the scope of medical equipment coverage if either so desires. We simply hold that, under present law, the Department may not arbitrarily restrict this coverage by regulation, because such coverage for durable medical equipment has been legislatively mandated. (See Jackson, supra, 215 Cal.App.3d at pp. 1515-1516; Ruth, supra, 8 Cal.App.4th at pp. 386-390.)
III. Disposition
The judgment is reversed. The matter is remanded to the trial court with instructions to grant the petition for writ of mandate.
Jones, P. J., and Gemello, J., concurred.
Notes
The Department does not repeat this argument on appeal, apparently in light of evidence that such a lift may be readily installed and removed.