United States District Court, D. Massachusetts
RONALD R. RENZI, Plaintiff,
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, Defendant.
MEMORANDUM AND ORDER
L. CABELL, U.S.M.J.
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.(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.
March 8, 2016, Kent County Hospital (the Hospital) submitted
a claim to National Government Services (NGS) 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).
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).
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).
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.
Relevant Factual Background
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
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).
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.
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