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Jones v. Tenncare6/20/2002
Background
Jones is, at the time of this opinion, nearly 55 years old and lives alone at her home in West Tennessee. Jones was diagnosed at age 16 with rheumatoid arthritis which has progressed to the point that Jones is currently bed-ridden and is able only to lie flat in her bed. Jones also is legally blind and, as a result, cannot see well enough to read or watch television. Jones also has been diagnosed with a panic disorder. Due to her disabilities, Jones is not physically able to perform daily tasks such as bathing or using a bed pan without assistance. Jones, however, is able to feed herself, drink liquids, take medication and use the telephone unassisted. Jones is unwilling to move out of her home into a nursing home. Jones' only income is Supplemental Security Income disability benefits. Jones has a daughter and a sister who live nearby and provide her some limited assistance.
The record shows Jones has been receiving home health services since approximately 1988. These services, performed by Certified Nursing Assistants ("CNA's"), were initially covered by federal Medicaid and after 1994, by TennCare. In October or November 1997, TennCare's managed care organization ("MCO"), BlueCare, notified Jones it was denying coverage for Jones' home health services. At the time of BlueCare's denial, Jones' treating physician, Dr. Jack G. Pettigrew, was ordering daily home health services for Jones. Upon Jones' request for reconsideration, BlueCare advised Jones in November 1997, that home health services would no longer be provided because the services constituted "custodial care - not medically indicated." Thereafter, Jones again appealed BlueCare's decision, and BlueCare referred Jones' appeal to the Bureau of TennCare. On December 17, 1997, TennCare's Associate Medical Director determined that Jones' home health services were not medically necessary. Jones' appeal was then transferred to the TennCare Office of General Counsel for an administrative hearing.
The administrative hearing was held in April 1998. Jones participated by telephone and was represented by counsel at the hearing. TennCare and BlueCare also participated as parties at the administrative hearing. Lisa Key, a Registered Nurse with the home health care agency which has provided services to Jones since 1988, testified. Key testified the CNA's assist Jones with bathing and hair care; assist Jones with her elimination needs; examine her skin for breakdown; assist with medication but do not administer medication; and ensure that Jones has food and water at her bedside.
Jones' treating physician, Dr. Pettigrew, did not testify at the hearing, but instead submitted a letter. In the letter dated February 10, 1998, Dr. Pettigrew wrote, in pertinent part, as follows:
[Jones] is a 49 year old totally bed-ridden rheumatoid arthritic female, who requires 24 hour care and she is unable to do any of her ADL's [activities of daily living] without total assistance. The family has been very good support for her. To my knowledge, since I've been caring for this patient from November 1985, I do not know of a single time she has required hospitalization due to the excellent coordinated care she has received through her family and Home Health.
I think it would be a tremendous disservice to the patient if her Home Health is terminated because of the multiple complications and probable hospitalizations that would occur. . . .
Dr. David Williams, a medical examiner for BlueCare, testified that he found Jones' request for daily home health care not to be medically necessary. In reviewing Jones' medical chart, Dr. Williams found significant Dr. Pettigrew's orders for per
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