This
matter is before me pursuant to the appeal of Caleb T. Thompson (Appellant),
from a final decision of the Respondent, South Carolina Department of Health
and Human Services (Department), denying the Appellant’s application for
Medicaid coverage. A contested case hearing was held on November 9, 2005. The
hearing officer later determined on November 27, 2005, that the evidence at the
contested case hearing supported the Department’s denial of TEFRA benefits for
Caleb Thompson. An appeal was filed timely with the Administrative Law Court
(ALC) pursuant to S.C. Code Ann. § 1-23-600 (Supp. 2005).
As set forth above,
this case is before the Court as an appeal of an agency action pursuant to S.C.
Code Ann. § 1‑23‑600(D) of the Administrative Procedures Act (APA)
upon appeal from a Final Order of the Department. As such, the Administrative
Law Judge sits in an appellate capacity under the APA rather than as an independent
finder of fact. In South Carolina, the provisions of the APA -- specifically
Section 1-23-380(A)(6) -- govern the circumstances in which an appellate body
may reverse or modify an agency decision. That section states:
The court may reverse or modify the decision if substantial
rights of the appellant have been prejudiced because the administrative
findings, inferences, conclusions or decisions are:
(a) in
violation of constitutional or statutory provisions;
(b) in
excess of the statutory authority of the agency;
(c) made
upon unlawful procedure;
(d)
affected by other error of law;
(e) clearly erroneous in view
of the reliable, probative and substantial evidence on the whole record; or
(f) arbitrary or capricious or
characterized by abuse of discretion or clearly unwarranted exercise of
discretion.
S.C. Code Ann. § 1-23-380(A)(6) (Supp.
2005).
A decision is supported
by “substantial evidence” when the record as a whole allows reasonable minds to
reach the same conclusion reached by the agency. Bilton v. Best Western
Royal Motor Lodge, 282 S.C. 634, 321 S.E.2d 63 (Ct. App. 1984). The
well-settled case law in this state has also interpreted the “substantial
evidence” rule to mean that a decision will not be set aside simply because
reasonable minds may differ on the judgment. Lark v. Bi-Lo, 276
S.C.130, 276 S.E.2d 304 (1981). The fact that the record, when considered as a
whole, presents the possibility of drawing two inconsistent conclusions from
the evidence does not prevent the agency's finding from being supported by
substantial evidence. Waters v. South Carolina Land Resources Conservation
Comm’n, 321 S.C. 219, 467 S.E.2d 913 (1996); Grant v. South Carolina
Coastal Council, 319 S.C. 348, 461 S.E.2d 388 (1995).
In
applying the substantial evidence rule, the factual findings of the
administrative agency are presumed to be correct. Rodney v. Michelin Tire
Co., 320 S.C. 515, 466 S.E.2d 357 (1996), citing Kearse v. State
Health and Human Services Finance Comm'n, 318 S.C. 198, 456 S.E.2d 892
(1995). Furthermore, the reviewing court is prohibited from substituting its
judgment for that of the agency as to the weight of the evidence on questions
of fact. Grant v. South Carolina Coastal Council, 319 S.C. 348, 461
S.E.2d 388 (1995), citing Gibson v. Florence Country Club, 282
S.C. 384, 318 S.E.2d 365 (1984). Finally, the party challenging an agency
action has the burden of proving convincingly that the agency's decision is
unsupported by substantial evidence. Waters, supra, citing Hamm v. AT&T, 302 S.C. 210, 394 S.E.2d 842 (1994).
DISCUSSION
Caleb Thompson is a
two-year-old child who was diagnosed with Cerebral Palsy in May of 2005. He
has experienced problems since his November 15, 2003 birth and had just begun
to walk in October 2005. On or about July 1, 2005, his mother applied for
benefits under the TEFRA program. Caleb was evaluated during that month and
was denied benefits on September 6, 2005 as not meeting the disability criteria
for TEFRA.
The Appellant’s mother,
Vanessa Thompson, submitted an appeal of the Department’s decision on her son’s
behalf. After being informed of her failure to timely file a brief in this
case, Ms. Thompson simply submitted a letter stating the following:
I am requesting a hearing from the
Department of Health and Human Services due to the denial of the Katie Beckett
Children – TEFRA for my son; Caleb Thompson. I feel he meets the disability
criteria to qualify for TEFRA.[1]
Appellant did not point to any error, either of fact or law made by the Hearing
Officer.[2]
Rather she merely restated her general objections and disagreement with the
Order as issued. She points to no particular portion of the evidence to
support her position. Nevertheless, to insure fairness the case is discussed
below.
TEFRA
Medicaid Program
The Medicaid Program is
a joint venture between the states and the federal government to provide
medical assistance to individuals meeting certain financial and other
criteria. The federal government provides the majority of funding for Medicaid,
although the states are required to provide "matching funds" that
contribute to meeting the costs of Medicaid. Standard federal rules set the
parameters within which the states may administer their individual Medicaid
Programs. See §1902 et seq. of the Social Security Act [42 USC §1396a et
seq.]. Caleb Thompson made application to the Medicaid program under the
TEFRA/Katie Beckett eligibility category. Established pursuant to the Tax
Equity and Fiscal Responsibility Act of 1982, TEFRA was made an eligibility
category in South Carolina in 1995. In order to qualify for TEFRA a child
must, among other criteria, be under age 19, live at home, meet the SSI
definition of disability, meet an institutional level of care and have a gross
income below $1635 per month and countable resources below $2,000. A parent’s
income and resources are not counted – only the child’s so some eligible
children may come from relatively affluent families. The child who meets the
criteria for TEFRA is eligible for the full range of Medicaid covered
services. Should the child need special services, which may be provided under
the Home and Community based waiver, he will have to apply to that program
separately.
Evidentiary
Review
Appellant submitted an
application for benefits with Form NF538 which is the form used to report the
disability evaluation. Appellant’s Form NF538 contained a compilation by Dr.
Walsh of medical reports furnished by Appellant and his physicians. The
application lists Appellant’s impairments as Cerebral Palsy and gross motor
delays. It states that the impairment is severe but does not equal or
functionally equal the listings in the SSI requirements. Dr. Walsh further
rated Appellant as having no limitation in acquiring and using information, no
limitation in the domains of attending and completing tasks, interrelating with
others, and moving and manipulating objects.
On the Pediatric
Physical Therapy Evaluation Summary and Plan of Care performed by physical
therapist Melissa Donaldson in February 2005, less than six months prior to the
hearing, Ms. Donaldson set short and long term goals for Appellant. In twelve
months or by February 2006, she expected him to, among other things, be able to
stand alone for three minutes while playing with a toy, walk thirty steps
independently and climb three steps with assistance. By the time of the
hearing, six months from the evaluation, she expected Appellant to be able to
walk for five steps. In her testimony, Appellant’s mother testified that he had
exceeded this goal. In response to the question from the Hearing Officer about
how far Appellant could walk, Ms. Thompson replied: “Actually he took 14 steps,
but he just tumble and falls over. He took 14 steps last week in therapy, and
it should be in Cindy’s notes, in the therapy.” The therapist, Ms. Cindy
McCravy, actually wrote that Appellant as of October 25, 2005 was taking 12
steps independently. Apparently between October 25 and the date of the
hearing, Appellant improved even more. As part of her evaluation, Ms.
Donaldson administered the Peabody Development Motor Scales – Second Edition to
Appellant. She found that only in locomotion was he seriously deficient. She
rated him at a -.73 standard deviation from the mean. In other words, his development
was behind what would be expected of the ‘average’ child but he was not very
much behind.
The Hearing Officer
performed an extensive analysis of the disability listings and compared them to
the medical reports. He found that Appellant did not meet the listing for
Cerebral Palsy found at 20 CFR, Part 404, Appendix 1 of Subpart P. Based on
the medical reports Appellant had no marked limitation in any of the required
domains as set out in 20 CFR 416.926a. Additionally based on The Peabody Development
Motor Scales – Second Edition, Appellant has a deviation from the mean of -.73
or not a full standard deviation. In order to have a marked impairment, 20 CFR
416.926a(e) requires a score of –2, or two standard deviations from the mean.
I recognize that
Appellant presented conflicting evidence to the Department’s case. In
particular, Ms. Thompson testified that though Appellant has taken twelve
steps, Appellant was off balance while taking those steps and he was dragging
his leg. Ms. Thompson also testified that Appellant has not reached his
developmental milestones and that he will have many difficulties in the future
including difficulty with his speech, balance, running and fatigue. Ms.
Thompson’s also submitted copies of books and articles on Cerebral Palsy.
Nevertheless, the
evidence set forth above establishes “substantial evidence” to support the
Department’s decision. Furthermore, the Department’s decision can not be set
aside simply because reasonable minds may differ on the judgment. Lark v.
Bi-Lo, supra. I therefore find that the Order of the Hearing
Officer should be upheld.
AND IT IS SO ORDERED.
______________________________
Ralph
King Anderson, III
Administrative
Law Judge
April 11, 2006
Columbia, South Carolina