Decision of the Director of the Arizona Health Care Cost Containment System Sustaining an Appeal of a Denial of Coverage (2005)

Court and Agency Decisions and Orders (including case law)

In this administrative decision, the Director of The Arizona Health Care Cost Containment System (AHCCCS)—Arizona’s Medicaid program—overturned the AHCCCS‘s denial of coverage of a liver transplant for a woman living with HIV. The decision concludes that the HIV-positive patient demonstrated the liver transplant she sought was medically necessary and non-experimental. In reaching this conclusion, the Director relied on expert testimony that demonstrated that a liver transplant was necessary to save the patient’s life, outcomes for liver transplant patients with controlled HIV are roughly the same as those for patients without HIV, and a transplant would not aggravate the patient’s HIV.

The Director declined to uphold the conclusion of the Administrative Law Judge to the extent that it suggested that AHCCCS’s policy listing “HIV positive” as a contraindication to organ transplantation violated state law. The Director held that the AHCCCS’s policy did not bar HIV positive individuals from transplantation. Rather, the policy required further analysis to determine whether a transplant was advisable in light of a beneficiary’s condition. The Director also rejected the Administrative Law Judge’s conclusion that the liver transplant was medically necessary because no other treatment existed that could prolong the beneficiary’s life. Rather, the AHCCCS contractor presented insufficient evidence to contradict the beneficiary’s evidence that the transplant was necessary and non-experimental given her medical history and asymptomatic HIV. Advocates using this case should note that the Director limited his holding to the facts of the case and therefore should note similarities or distinctions between their case and this one.

The patient’s brief is also available on the Resource Bank here.