Matter of Gur-Arie v Zucker
Categories
Attorneys and Parties
Brief Summary
Medicaid coverage for durable medical equipment, specifically whether a replacement Convaid Cruiser stroller was medically necessary for a severely disabled adult with quadriplegic cerebral palsy.
After a fair hearing, an Administrative Law Judge (ALJ) acting for the New York State Department of Health (DOH) upheld the August 13, 2020 denial of prior approval for the stroller on the grounds that it was not medically necessary and not cost effective.
The Appellate Division annulled the DOH determination dated April 6, 2021, which had upheld the denial of the petitioner's request for the stroller, and directed the DOH to order the Kings County Department of Social Services to provide it.
The court found the agency determination was not supported by substantial evidence. The petitioner's proof, including testimony and a physical therapist's letter, showed the stroller would increase weight-bearing activity, help prevent muscle atrophy, benefit the petitioner's heart, lungs, and bones, and improve his functional ability, satisfying Medicaid medical-necessity standards.
Background
David Gur-Arie is a 30-year-old man with significant disabilities, including quadriplegic cerebral palsy. He is nonambulatory and nonverbal. He uses a Solara tilt-in-space wheelchair as his primary mobility and seating device. In 2013, he obtained a Convaid Cruiser stroller through primary insurance as a secondary device used for weight-bearing transfers at home and transportation to therapeutic services. On July 15, 2020, Home Medical Equipment, LLC submitted a prior approval request to the New York State Department of Health (DOH) for a replacement stroller. The DOH denied the request on August 13, 2020. The petitioner then sought a fair hearing under 18 NYCRR 513.8 [administrative fair-hearing procedure to review a Medicaid denial], and after the March 2, 2021 hearing, the denial was upheld. He then commenced a proceeding under CPLR article 78 [procedure for judicial review of administrative action].
Lower Court Decision
The agency determination under review held that the requested Convaid Cruiser stroller was not medically necessary and not cost effective. Although the petitioner had the burden under 18 NYCRR 513.3(a) [Medicaid applicant must show the requested care, services, or supplies are medically necessary and that prior-approval requirements are satisfied], the ALJ concluded that burden was not met and upheld the denial.
Appellate Division Reversal
The Appellate Division dismissed the petition only as against Michael P. Hein, Commissioner of the Office of Temporary and Disability Assistance (OTDA), because he did not make the final determination under review. As to Howard Zucker and the DOH, however, the court granted the petition, annulled the April 6, 2021 determination, and ordered the DOH to direct the Kings County Department of Social Services to provide the stroller. The court held that the record established medical necessity under 18 NYCRR 513.1(c) [defines care or supplies as necessary if they meet the recipient's medical needs, reduce disability, restore the recipient to the best possible functional level, or improve capacity for normal activity]. The court emphasized that the stroller was not merely for caregiver convenience; it had therapeutic and functional benefits. It also noted that the opinions of the petitioner's treating practitioners were entitled to significant weight under 18 NYCRR 513.6(e) [treating practitioners' opinions are entitled to significant weight].
Legal Significance
This decision reinforces that Medicaid medical-necessity determinations for durable medical equipment must be grounded in substantial evidence and evaluated in light of the recipient's actual functional circumstances. The case underscores that equipment may qualify as medically necessary even if it also assists caregivers, so long as the evidence shows therapeutic, rehabilitative, or functional benefit to the recipient. It also confirms that courts will annul agency denials when the record unequivocally demonstrates medical necessity under 18 NYCRR 513.1(c).
When a Medicaid recipient presents strong evidence from treating providers that requested equipment will reduce disability, improve function, and support daily therapeutic goals, the DOH cannot deny coverage based on a thin or unsupported view that the equipment is merely convenient or not cost effective.