TUFTS MEDICAL CENTER, INC.
Daniel TSAI, In his Capacity as Director, Office of Medicaid
MEMORANDUM OF DECISION AND ORDER ON PLAINTIFFâS
MOTION FOR JUDGMENT ON THE PLEADINGS
Douglas H. Wilkins, Justice of the Superior Court
Medical Center, Inc. ("Tufts") filed this appeal
under G.L.c. 30A, § 14 from a final decision
("Decision") of the Director of the Office of
Medicaid ("MassHealth"), denying reimbursement for
inpatient services that it provided to two MassHealth
recipients. The Court held a hearing on January 18, 2018.
After MassHealth filed the administrative record pursuant to
Superior Court Standing Order 1-96. Tufts filed a Motion for
Judgment on the Pleadings ("Motion"), which
MassHealth has opposed. Based upon the courtâs review of the
administrative record, motion and memorandum and upon
consideration of oral arguments, the Motion is ALLOWED IN
PART AND DENIED IN PART.
provided inpatient services to two MassHealth recipients,
referred to in the record as patients BC and MW. It alleges
that the Decision misrepresents, mischaracterizes, or
disregards the facts in evidence. Specifically, Tufts claims
that Patient BCâs vital signs and other medical conditions
were either inaccurately represented or mischaracterized in
the Final Decision. Tufts also claims that the Decision
ignored Patient MWâs X-rays and nasopharyngeal scope
procedure and their results, as well as not adequately
addressed Patient MWâs respiratory conditions.
held a hearing on October 18, 2016 and May 4, 2017. The
primary witnesses were the physician experts for Tufts (Dr.
Durgham as to BC and Dr. Weingart as to MW) and MassHealth
(Dr. Connolly as to BC and Dr. Seigel as to MW). Their
testimony, and the medical record support for the Decision,
are discussed below.
Court "may set aside the decision of an administrative
agency if it is not supported by substantial evidence."
Cobble v. Commissioner of Social Services, 430 Mass.
385, 390 (1999). See G.L.c. 30A, § 14(7)(e).
"[S]ubstantial evidence" is "such evidence as
a reasonable mind might accept as adequate to support a
conclusion." G.L.c. 30A, § 1(6). When reviewing an
agency derision, the Court must give "due weight to the
experience, technical competence, and specialized knowledge
of the agency, as well as to the discretionary authority
conferred upon it." G.L.c. 30A, § 14(7). "[T]o
determine whether an agencyâs decision is supported by
substantial evidence, we examine the entirety of the
administrative record and take into account whatever in the
record fairly detracts from the supporting evidenceâs
weight." Cobble, 430 Mass. at 390, citing
New Boston Garden Corp. v. Assessors of Boston, 383
Mass. 456, 466 (1981). The appealing partyâs burden to
demonstrate the invalidity of the agency decision "is
heavy." Springfield v. Depât of Telecomms. &
Cable, 457 Mass. 562, 568 (2010) (citation omitted).
misstatement of the record may show a lack of substantial
evidence. "While the task of assessing the credibility
of witnesses is one uniquely within an agencyâs discretion
[citation omitted], this court may modify or set aside
findings and conclusions that are ... unsupported by
substantial evidence." Bettencourt v. Board of
Registration in Medicine, 408 Mass. 221, 227 (1990)
(faulting the agencyâs omissions, i.e. its failure to
consider a certain line of evidence). Thus, where the agency
has said there is "no evidence" to support a
particular proposition, the presence of evidence on that
point is enough to negate MassHealthâs substantial evidence
Critical Vital Signs
claims that the correct baseline for patient BCâs pulse
oximetry was 97-99% on room air, not 86-91% as stated in the
Decisionâs second Finding of Fact. Pl.âs Mem. at 9.
Appellantâs Oppân to the Proposed Decision at 2. It also
claims that there was evidence of hypoxemia (oxygen
deficiency), contrary to the seventh Finding of Fact in the
Final Decision. Pl.âs Mem. 9. MassHealth does not
specifically address Tuftsâ claims regarding either the
baseline for pulse oximetry or the existence of hypoxemia.
See Def.âs Oppân 13-14. Instead, MassHealth summarily states
that "[t]here was no evidence of hypoxemia."
Id. at 3.
Decision addresses both the baseline for patient BCâs pulse
oximetry and the existence or lack of hypoxemia. In its
Summary of Evidence, it acknowledges testimony from Dr.
Connolly and Dr. Durgham. Dr. Connolly testified that pulse
oximetry of Patient BC was 85% and the baseline was noted to
be 86-91%. Final Decision 4. He further testified that
"[t]here was no evidence of hypoxemia."
Id. Although the Decision does not address Tuftsâ
specific claims regarding the baseline or existence of
hypoxemia, it notes Dr. Durghamâs testimony that there was
"a deviation of his vital signs." Id. at
pulse oximetry reflected in the medical records varies. The
Triage Assessment from the Emergency Department indicates
that 86-91% "O2sats" was reported as "normal
for him." Ex. 4A at 20. In contrast, the EMS note states
that Patient BCâs vital sign was "97-99% on RA."
Id. at 16. The PICU Admit Note also states that his
"O2 saturations [were] 95% to 98%." Id. at
34. Given the conflicting testimony and records, MassHealth
reasonably could conclude that the baseline was 86-91% and
that there was no evidence of hypoxemia, that is, there was
no deviation in Patient BCâs vital ...