SC Administrative Law Court Decisions

This is an appeal from a final Administrative Decision of the South Carolina Department of Health and Human Services (DHHS) dated June 8, 2000. The DHHS decision rejected Appellant's application for Medicaid benefits through the Aged, Blind and Disabled (ABD) program. DHHS based its decision on a report by the South Carolina Department of Vocational Rehabilitation (VR) dated February 25, 2000 that Appellant did not have any "severe" impairments rendering her "disabled" for purposes of the ABD program. DHHS refers applicants for Medicaid under the ABD program to the Disability Determination Division of the VR for independent disability determinations. Appellant timely filed an appeal on June 30, 2000, and each party filed briefs with the Administrative Law Judge Division (ALJD).

Pursuant to the authority provided under ALJD Rule 39, I conclude that no oral argument was required in this matter. Further, after reviewing the record on appeal and considering the briefs submitted by both parties, I conclude that the decision of DHHS must be affirmed.

The Administrative Procedure Act (APA), S.C. Code Ann. §§ 1-23-310 et seq. (Rev. 1986 and Supp. 1999), sets out the standard of review applicable to an appeal of an agency's decision. Accordingly, the ALJD is limited to determining whether substantial rights of the appellant have been prejudiced because the administrative findings, inferences, conclusions, or decisions are clearly erroneous in view of the reliable, probative and substantial evidence on the whole record. S.C. Code Ann. § 1-23-380 (A)(6)(e) (Supp. 1999); see Waters v. S.C. Land Resources Conservation Comm'n, 321 S.C. 219, 467 S.E.2d 913 (1996); Palmetto Alliance, Inc. v. S.C. Public Service Comm'n, 282 S.C. 430, 319 S.E.2d 695 (1984). In accordance with the foregoing provision, the Hearing Officer's decision may only be set aside if unsupported by "substantial evidence."

"Substantial evidence" is not a mere scintilla of evidence nor the evidence viewed blindly from one side of the case but is evidence which, considering the record as a whole, would allow reasonable minds to reach the conclusion that the administrative agency reached or must have reached in order to justify its action.

Lark v. Bi-Lo, Inc., 276 S.C. 130, 134, 276 S.E.2d 304, 306 (1981); see Bilton v. Best Western Royal Motor Lodge, 282 S.C. 634, 321 S.E.2d 63 (Ct. App. 1984). A decision will not be set aside simply because reasonable minds may differ on the decision. Lark, 276 S.C. at 134, 276 S.E.2d at 306. 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. S.C. 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). The burden is on the appellant to show convincingly that the decision of DHHS requires reversal. See Hamm v. AT & T, 302 S.C. 210, 394 S.E.2d 842 (1990).

The Medicaid Program is a joint venture between the federal government and the States to provide medical and other assistance to persons meeting certain criteria. In South Carolina, DHHS administers the Medicaid Program. The federal government requires that individuals meeting certain federal criteria be eligible for Medicaid. At their option, states may extend Medicaid coverage to other individuals and may also offer additional services to individuals. South Carolina affords such optional coverage to a class of individuals meeting criteria of the "Aged, Blind and Disabled" Program.

Under the ABD Program, an applicant must establish that (1) the applicant's assets and income fall below certain limits; and (2) the applicant is "aged" (over 65), "blind" (as determined under SSA regulations) or "disabled" (as determined under SSA regulations). The federal government has established specific criteria that are used by the SSA to determine when an applicant is "disabled" under the ABD program. Since applicants may concurrently apply for both federal SSI benefits and Medicaid benefits, federal law streamlines the application process by requiring that the States adopt a prior SSA disability determination if the following three requirements are met: (1) SSA's determination considers the same alleged disabling factors that have been raised in the Medicaid application; (2) SSA's determination covers the same alleged period of disability presented to DHHS in the Medicaid application; and (3) SSA's determination is made within certain time limits. 42 C.F.R. § 435.541. When these three requirements are met, the SSA determination remains binding for purposes of the Medicaid Program until the determination is changed by SSA. 42 C.F.R. § 435.541(b)(1)(I).

Both DHHS and the federal government have contracted with VR to conduct disability determinations for their respective programs. VR evaluates the case based on federal disability criteria and determines whether the applicant is "disabled." When VR evaluates an SSI application, it acts on behalf of the federal government. When VR evaluates a Medicaid application, it acts on behalf of South Carolina.

In this case, VR concluded that Appellant did not have a "severe" impairment and, therefore, Appellant was not "disabled." Appellant was 53 years old at the time of her application and had a tenth grade education. According to DHHS, Appellant was not engaged in "substantial gainful activity"; in fact, Appellant testified that she had not worked since 1972. Therefore, VR evaluated Appellant's medical condition to determine whether she suffered from a "severe" impairment that prevented her from working. VR obtained medical records and considered not only Appellant's diabetic condition, but also other conditions identified in her application and in her medical records. These conditions included: gastrointestinal problems, arthritis, thyroid problems, vision problems, and a "trigger" finger of the left thumb. VR hired a medical consultant to review Appellant's medical conditions. VR identified no "severe" impairment that could last twelve months to qualify as "disabled" under the ABD program.

On appeal before the Hearing Officer, Appellant claimed she could not control her blood sugar levels and that she is afraid to drive, her right foot swells (diagnosed as cellulitis), and she has trouble with her left thumb. No physician has advised her not to drive, although one of Appellant's acquaintances testified at the hearing to corroborate that she avoids driving. Appellant testified that she could not seek medical attention for several of her ailments because she could not afford the medical bills. The record includes medical records of Appellant's treating physician. At the hearing, two witnesses testified on behalf of DHHS concerning the physical evaluation of Appellant and Appellant's complaints. They similarly indicated that Appellant did not have any "severe" impairments.

The Hearing Officer considered the statements that support that Appellant should not work. These statements, which were not substantiated by specific medical findings, were the following:

(1) two statements from Dr. Jeanne L. Halyard, Appellant's treating physician, that "[t]he combination of her medical problems and duty to her husband prevent[ed] her from being employed outside the home" and "[Appellant] [wa]s unable to work outside the home as a result of her medical problems as well as the care she needs to provide her husband."

(2) a statement from Dr. Andrew Gresko, the cardiologist of Appellant's husband, that she needed to be home to take care of her husband.

There was no statement by a physician or specific medical findings that Appellant's medical condition alone rendered her unable to work, and therefore "disabled."

Under 20 C.F.R. 416.927(d)(2), the treating physician's opinion is given controlling weight if it is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with other substantial medical and non-medical evidence in the record. In this case, DHHS concluded that Appellant's medical record contains no substantiating evidence of a "severe" impairment, or combination of impairments that qualify as "severe." Therefore, DHHS concluded that Appellant was not "disabled."

This tribunal understands and is sympathetic to Appellant's need to stay at home to care for her husband and her inability to pay for medical treatment. Nevertheless, this tribunal cannot substitute its judgment for that of the agency except where a "manifest or gross error of law has been committed by the administrative agency." Lark v. Bi-Lo, Inc., 276 S.C. 130, 134, 276 S.E.2d 304, 307 (1981). No such error has been established here, as Appellant has not adequately substantiated her medical claims. Further, the record supports the Hearing Officer's findings of fact and conclusions of law. In this instance, the Appellant has not proven convincingly that the decision of DHHS requires reversal. See Hamm v. AT&T, 302 S.C. 210, 394 S.E.2d 842 (1990).

Finally, this tribunal may rule on this matter without oral argument. ALJD Rule 39 provides that:

[t]he Clerk of the Division shall provide at least twenty (20) days notice of oral argument. The oral argument shall follow the procedure in Rule 218, SCACR. In the discretion of the administrative law judge, oral argument may not be required.

Pursuant to the authority provided in Rule 39, I find that oral argument is not required.

Based upon the record and the applicable law, the Order and Decision of the Hearing Officer is AFFIRMED.

AND IT IS SO ORDERED.

_____________________________

John D. Geathers

Administrative Law Judge

September 14, 2000

Columbia, South Carolina