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Administrative Law Court
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SC Administrative Law Court Decisions

CAPTION:
Trenton Atkinson vs. SCDHHS

AGENCY:
South Carolina Department of Health and Human Services

PARTIES:
Petitioners:
Trenton Atkinson

Respondents:
South Carolina Department of Health and Human Services
 
DOCKET NUMBER:
01-ALJ-08-0279-AP

APPEARANCES:
Petitioners & Representative: Trenton Atkinson, Paul Townsend McChesney, Esquire

Respondents & Representative: South Carolina Department of Health and Human Services, George Burnett, Esquire

Parties Present: Both Parties
 

ORDERS:

ORDER

I. Introduction



In this matter, Trenton Atkinson (Atkinson), a minor, claims a disability status and asserts he is entitled to Medicaid benefits. The Department of Health and Human Services (DHHS) denied the disability claim and Atkinson now invokes the appellate jurisdiction of the Administrative Law Judge Division seeking to reverse DHHS's decision. See S.C. Code Ann. §§ 1-23-380 and 44-6-190 (Supp. 2000). Upon reviewing the record established below, this matter must be remanded for further consideration consistent with the analysis presented in this Order.



II. Analysis



For Medicaid purposes, an individual under 18 is disabled:



if that individual has a medically determinable physical or mental impairment, which results in marked and severe functional limitations, and which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.



42 U.S.C. § 1382c(a)(3)(C)(i) (Cum.Supp.2000).



In deciding if the disability criteria listed above are met, a plainly stated three step process is used:



We follow a set order to determine whether you are disabled. [1] If you are doing substantial gainful activity, we will determine that you are not disabled and not review your claim further. [2] If you are not doing substantial gainful activity, we will consider your physical or mental impairment(s) first to see if you have an impairment or combination of impairments that is severe. If your impairment(s) is not severe, we will determine that you are not disabled and not review your claim further. [3] If your impairment(s) is severe, we will review your claim further to see if you have an impairment(s) that meets, medically equals, or functionally equals in severity any impairment that is listed in appendix 1 of subpart P of part 404 of this chapter. If you have such an impairment(s), and it meets the duration requirement, we will find that you are disabled. If you do not have such an impairment(s), or if it does not meet the duration requirement, we will find that you are not disabled.



20 C.F.R. § 416.924(a) (2000).



In the instant case, all agree that Atkinson, a child in elementary school, is not "doing substantial gainful activity" so that the first meaningful inquiry is examining "your physical or mental impairment(s) first to see if you have an impairment or combination of impairments that is severe."



Further, all agree that Atkinson has two severe physical impairments. First, Dr. Constance Yearling determined that Atkinson suffers from a severe physical impairment due to a condition known as ornithine transcarbamylast deficiency (OTC). OTC is an inability to properly break down ammino acids. The result of this condition is a build up of ammonia in the blood stream which, if uncontrolled, leads to permanent and severe brain damage and may lead to death. Second, Dr. W. Pearce McCall found that Atkinson suffers from a severe physical impairment of Attention Deficit Hyperactivity Disorder (ADHD). ADHD is a neurological condition that may cause impulsiveness, restlessness, disorganization, hyperactivity, distractibility, and mood swings.



Since severe physical impairments are present, the third step requires determining if Atkinson has an "impairment that meets, medically equals, or functionally equals in severity any impairment that is listed in appendix 1 of subpart P of part 404 of this chapter." Indeed, this third step is the point of disagreement between the parties.



Atkinson does not argue that his impairments meet or medically equal one of the "listed impairments." Rather, he argues that the decision below erred in concluding that his impairments are not functionally equivalent to the listed impairments. Functional equivalence is a valid means of demonstrating disability and requires an assessment of the severity of the functional limitations imposed by Atkinson's impairments. Atkinson's functional limitations must be assessed in six areas:



(i) Acquiring and using information;

(ii) Attending and completing tasks;

(iii) Interacting and relating with others;

(iv) Moving about and manipulating objects;

(v) Caring for yourself; and,

(vi) Health and physical well-being.



See § 416.926a(b)(1)(i)-(vi).



If the assessment results in a finding of two "marked" limitations or one "extreme" limitation, a conclusion of disability is reached. See § 416.926a(a) and (b)(2). The decision below found no disability since Atkinson had no extreme limitation and has a marked limitation only in the area of attending and completing tasks.



Atkinson argues the decision below is in error. He argues that the evidence confirms a second marked limitation in the area of "caring for yourself."



To decide if the evidence supports the finding of no marked limitation in the area of "caring for yourself," the judge is concerned with whether the finding is supported by substantial evidence. Lark v. Bi-Lo, 276 S.C. 130, 276 S.E.2d 304 (1981); S.C. Code Ann. § 1-23-380(A)(6) (Supp. 2000). However, before the judge can decide if substantial evidence supports the finding, the appellate body must have a finding that is detailed enough to allow the reviewing body to "determine whether the findings are supported by the evidence and whether the law has been applied properly to those findings." Porter v. S.C. Public Serv. Comm'n, 333 S.C. 12, 507 S.E.2d 328 (1998). At a minimum, the degree of detail in the finding must provide a rationale for how the finding was reached. Kiawah Property Owners Group, v. Public Service Commission of South Carlina and Kiawah Island Utility, Inc., 338 S.C. 92, 525 S.E.2d 863 (1999). Specifically, the reviewing body "will not accept an administrative agency's decision at face value without requiring the agency to explain its reasoning. Porter v. S.C. Public Serv. Comm'n, 333 S.C. 12, 507 S.E.2d 328 (1998).



One class of findings that are the most lacking in detail and in rationale are those findings categorized as implicit findings. Implicit findings rely upon unstated and thus "implied" conclusions and facts that are devoid of the detail required to determine if the findings are supported by the evidence or to decide if the law has been properly applied to those findings. Able Communications, Inc. v. South Carolina Public Service Com'n, 290 S.C. 409, 351 S.E.2d 151 (1986). Thus, if a material fact is in dispute, the fact-finder may not rely upon implicit fact finding, but instead the fact-finder must make specific and express findings of fact expressing a rationale for the conclusion reached. Aristizabal v. Woodside-Division of Dan River, 268 S.C. 366, 234 S.E.2d 21 (1977).



In the instant case, the conclusion that Atkinson has a less than a marked limitation in the functional domain of "Caring for Yourself" is based on implicit fact finding:



The Petitioner takes care of his personal needs. He is frustrated over his learni ng difficulties and his treatment regimen required by his OTC. The Petitioner has a less than marked limitation in the functional domain of "Caring for Yourself" and I so find.



The finding that Atkinson takes care of his personal needs lacks the required detail to establish the rationale relied upon to reach such a conclusion. Indeed, such detail is all the more required since Atkinson's argument below was that he cannot take care of his personal needs since OTC prevents him from obtaining proper food sustenance without medical intervention. The lack of detail and lack of rationale improperly leaves the appellate body to speculate on how the disputed issue was resolved and prevents a fair determination on whether the finding is supported by substantial evidence or whether the law was correctly applied.



For example, what activities constitute having the ability to take care of personal needs? Does it include the ability to feed oneself and, if so, what activities establish that Atkinson is capable of "feeding" himself? Does the decision conclude that feeding means only that Atkinson possesses the physical coordination to do so? Or does the decision below mean to hold that a child with Atkinson's impairment can be reasonably expected to rely upon his parents for "feeding" and that such reliance upon parents is proper in this case? If reliance upon parents is a factor in the finding below, do the parents lack the knowledge to provide proper food sustenance? Is Atkinson's ability to feed himself achieved only with daily consultation with and intervention by a team of physicians and nutritionists and if so what impact does such a finding have on deciding that Atkinson takes care of his personal needs?



In summary, explicit findings are required in light of Atkinson's view that his basic necessity of food sustenance cannot be supplied by himself or by reliance upon his parents, but can only be supplied by a team of physicians and nutritionists who monitor his protein intake, calorie consumption, blood level ammonia, and general overall condition on a weekly and often daily basis. Nothing in this order is intended to imply or suggest an answer to any of the questions posed above or to the ultimate issue of whether Atkinson is disabled. Rather, such questions and issues are best answered by the fact finder in the first instance, the hearing officer.



IV. Order



ACCORDINGLY, this matter is remanded and the Order below is vacated. The hearing officer shall re-examine the record and issue a new order. The new order will not reassess the other five areas of functional limitations but shall only reassess Atkinson's limitation in the functional domain of "Caring for Yourself." In such reassessment, the Order shall establish findings of facts and conclusions of law supported by such detail and rationale as are necessary for a proper decision.



Finally, I do not retain jurisdiction over this matter. Rather, an appeal, if such is sought, must be filed in a timely and proper manner so that a new appeal results.



AND IT IS SO ORDERED







______________________

RAY N. STEVENS

Administrative Law Judge



Dated: November 30, 2001

Columbia, South Carolina


Brown Bldg.

 

 

 

 

 

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