Hinds v. Blue Cross and Blue Shield of Tenn., Inc.

No. 3:95-0508 (M.D. Tenn. Dec. 28, 1995). ; Clearinghouse Number: 50704

Description

Bowel and Liver Transplant for Three-Year-Old with Short-Bowel Syndrome Is a Covered Service Under Medicaid and TennCare

Abstract

Granting plaintiff’s motion for a preliminary injunction, the district court has ordered defendant insurer to fund plaintiff’s bowel and liver transplant. Plaintiff is a three-year-old, Medicaid-eligible child who is enrolled in TennCare, Tennessee’s Medicaid demonstration project. Defendant insurer has contracted with the state to provide managed health care services to Medicaid-eligible enrollees under the demonstration project. Plaintiff suffers from short-bowel syndrome and must undergo up to 13 hours daily of intravenous feeding in order to survive. The intravenous feeding has caused liver damage, and her doctors have recommended that she undergo a liver and bowel transplant. Defendants, insurer and the Tennessee Department of Health, which administers TennCare, refused to authorize funds for the dual transplant because in their determination such treatment was not covered under Medicaid law or the TennCare program. The district court rejected the argument that, under 42 U.S.C. § 1396b(i), a state has complete discretion to determine which transplants it will fund. The court also found that plaintiff was likely to succeed on her claim that a small-bowel transplant was not experimental but a medically necessary procedure and the only one currently available to treat her condition; a bowel and liver transplant was a covered service under the TennCare risk agreement in plaintiff’s case because it was nonexperimental, medically necessary, performed within accepted modes of treatment, and cost-effective. However, the court rejected plaintiff’s claim that defendant insurer misled her into believing that it would cover transplant services in violation of the state’s consumer protection act.

Additional Information

Attorney Information
Plaintiff represented by Lenny Croce, Paul Drozdowski, Rural Legal Services of Tennessee, Inc., P.O. Box 5209, Oak Ridge, TN 37831, (615) 483-8454.
Docket Date
1995-12-28 00:00:00+00:00

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