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Renzi v. Price

United States District Court, D. Massachusetts

March 29, 2019

RONALD R. RENZI, Plaintiff,
v.
ALEX AZAR, Secretary, U.S. Dep't of Health and Human Services, ANDREW E. LELLING, U.S. Attorney for the District of Massachusetts, and WILLIAM BARR, U.S. Attorney General,[1] Defendant.

          MEMORANDUM AND ORDER

          DONALD L. CABELL, U.S.M.J.

         I. Introduction

         Plaintiff Ronald Renzi moves for summary judgment and an order reversing a decision of the Secretary of the U.S. Department of Health and Human Services (HHS) denying his wife Phyllis Renzi Medicare coverage for dental extractions and related services.[2](D. 27). The Secretary in turn cross-moves for summary judgment and an order affirming his final decision. (D. 28). Following a careful review of the record, the plaintiff's motion will be denied and the Secretary's motion will be allowed. The reasons for these rulings are explained below.

         II. Procedural History

         On March 8, 2016, Kent County Hospital (the Hospital) submitted a claim to National Government Services (NGS)[3] requesting Medicare Part B coverage for dental extraction and related services provided to Phyllis Renzi. (HHS Administrative Record, pg. 171 (R.)). NGS denied the claim twice, first on March 10, 2016, and then again on June 2, 2016 following the Hospital's request for reconsideration. (R. 166, 171).

         On September 3, 2016, the plaintiff requested reconsideration by a Medicare qualified independent contractor (QIC). (R. 164-65). On October 26, 2016, the QIC rendered an unfavorable decision, concluding that the services did not meet the criteria for Medicare coverage. (R. 151-62).

         On February 15, 2017, an administrative law judge (ALJ) found that the services were covered by Medicare Part A as inpatient hospital services because of Phyllis Renzi's underlying medical condition. (R. 30-36, 183-94).

         However, on June 14, 2017, the Medicare Appeals Council (MAC) on its own motion decided to review the ALJ's decision. (R. 6). The MAC determined that the ALJ erred in finding the services to be inpatient and held that the services were not covered under Medicare Part A or Part B. (R. 8-12). The plaintiff subsequently initiated this action seeking review of the Secretary's final decision as made by the MAC.

         III. Relevant Factual Background

         Phyllis Renzi suffered from various autoimmune disorders, including scleroderma (CREST syndrome) and Raynaud's phenomenon. (R. 57-58). Her medications induced xerostomia (dry mouth) that caused her to develop severe gingivitis and gum disease. (Id.). Due to these issues, Phyllis Renzi was evaluated by Dr. Leland Blough, DMD, who recommended she have her remaining teeth extracted. (R. 59). After consulting with her other treating physicians, Dr. Blough concluded that the extractions should take place at the Hospital under anesthesia. (Id.).

         On the morning of January 20, 2016, Phyllis Renzi was admitted to the Hospital for oral surgery, where she received preoperative monitoring, IV anesthesia during surgery, postoperative monitoring from a recovery room, and prescribed medication. (R. 71, 94, 107-22). She was discharged almost seven hours later the same day. (R. 71).

         IV. Discussion

         The plaintiff raises three arguments in challenging the MAC's decision to reverse the ALJ's ruling. He argues first that the ALJ did not err in finding that the services provided to his wife were inpatient. He argues next that he is entitled to coverage because the dental services she received were incident to and an integral part of an otherwise covered procedure, treatment of his wife's scleroderma. Finally, the plaintiff maintains that he is entitled to coverage because he, his wife and Dr. Blough did not know, and could not reasonably have been expected to know that the services she received would not be covered.

         The Secretary argues that substantial evidence in the record supports the MAC's determination that the dental services were performed outpatient, that the services were not incident to and an integral part of an otherwise covered ...


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