BODY: The Idaho Supreme Court invalidated a state regulation excluding coverage of all medical procedures for the treatment of obesity, and directed the Idaho Medicaid agency to provide coverage for gastric bypass surgery intended to treat a Medicaid recipient's obesity. McCoy v. Idaho Department of Health and Welfare, No. 21563 (Idaho 1995).
Background . . . The Medicaid recipient, who also received Supplemental Security Income (SSI), was disabled by morbid obesity. The recipient's physical condition resulted in a number of other health problems, including congestive heart failure, hypertension, apnea (a sleep disorder), and joint problems. The Medicaid recipient failed to complete any of the several weight reduction programs through which she attempted to lose weight. The recipient's physician referred her for evaluation as a possible candidate for gastric bypass surgery; the consulting physician opined that the surgery was appropriate for the recipient and that the surgery would correct most of the recipient's other health problems. At a hearing conducted by the state Medicaid agency, both physicians testified that the surgery was medically necessary to treat the Medicaid recipient's health problems. However, reimbursement for the surgery was denied pursuant to a state regulation excluding coverage for all medical procedures intended to treat obesity. The trial court sustained the denial of coverage on the grounds that the state was entitled to establish priorities for the medical needs of its citizens. On appeal, the recipient contended that the state agency was required to provide coverage for her surgery, under the federal Medicaid statute, because the surgery was medically necessary to treat the physical problems stemming from her obesity.
Expense of Treating Health Problems Could Exceed Cost of Surgery . . . The state supreme court vacated the administrative decision denying coverage for the gastric bypass surgery upon finding that the state regulation upon which the state Medicaid agency relied was invalid. The overall cost to the public for treating the Medicaid recipient's physical problems could easily exceed the cost of the single surgical procedure, which was not merely cosmetic but was medically necessary, the court reasoned. Accordingly, the court held that the state regulation was fatally overbroad because it arbitrarily denied funding for all procedures treating obesity, even though a particular procedure might be the only treatment available for a condition not excluded under the state Medicaid plan. Although the state Medicaid agency's justification for denying coverage of the surgery was erroneous, the court concluded that the agency's position did not justify the imposition of attorney fees.
