Court says state erred in refusing to pay for surgery for teen with HIV

February 19, 2008 01:10 PM Email| Comments (0)| Text size – +

(Josh Reynolds for the Boston Globe/file 2006)

By John R. Ellement, Globe Staff

Saying the state ignored its own rules, the Massachusetts Appeals Court today ordered MassHealth to revisit its decision not to pay for surgery for an HIV-positive teenager who developed a hump on her neck from powerful medications.

Ashley Shaw's doctors at Children’s Hospital Boston said in 2004 that she needed to get the large pad of fat removed from her neck because it was changing her posture, giving her headaches, and leading her to be withdrawn from others. The day before surgery, MassHealth notified Ashley’s mother, Elizabeth Shaw, that it would not pay for the liposuction procedure because it did not qualify for payment under state and federal Medicaid rules.

Concerned for her daughter’s health, Elizabeth Shaw agreed to pay for the surgery, while at the same time getting support from lawyers at Gay & Lesbian Advocates & Defenders who feared children facing a lifetime of health issues related to AIDS and HIV will wrongly lose health benefits. After learning Shaw had agreed to pay the estimated $2,000 cost, MassHealth said it would not pay the bill retroactively.

In a unanimous ruling, a three-judge panel of the Appeals Court said today the paramount issue for MassHealth is not when a claim is filed, but the medical needs of the patient at the time the surgery is performed.

“To treat prior authorization as overriding all other considerations is not consistent’’ with state rules, Judge Elspeth Cypher wrote for the court. “It is apparent that it principally is concerned with the medical necessity of a request as the controlling prerequisite for payment of services for certain procedures.’’

Elizabeth Shaw said her daughter, now 18 years old, has fully recovered. "The surgery was competely successful,'' the Boston resident said in a telephone interview today.

Shaw called the decision a partial victory because she must still convince MassHealth the surgery was needed. She also said her daughter has interacted with MassHealth since 2004 without any difficulties.

"She was a very, very sick as a a little girl and she is healthy now,'' Shaw said.

Janson Wu, an attorney with GLAD, applauded the ruling. “What we hope is that this decision means that children like Ashley who are really a generation of children living with HIV/AIDs through adulthood will be given access to necessary healthcare,’’ he said.

The litigation began under the Romney administration. A spokeswoman for the Patrick administration said the ruling was being reviewed.