D.N., a 38 year-old man, was seriously injured in an automobile accident, resulting in quadriplegia. D.N. cannot sit, stand, change positions on his own, or move his arms or legs. He needs to be repositioned when he sleeps to avoid bedsores and maintain skin integrity. As a result, D.N. is eligible to receive Medicaid assistance in the form of in-house personal care assistant (PCA) services to perform most of his day-to-day personal activities for him, such as personal grooming, bathing, dressing, eating, drinking, and taking medications.

Amerigroup, the Managed Care Organization (MCO) that functions as an agent of New Jersey’s state Medicaid agency, reduced the number of PCA services hours D.N. received from 24 hours per day, to 15 hours per day.

D.N. appealed the MCO’s decision, challenging the reduction in PCA services. Petitioner’s witness testified that his medical condition required him to be monitored and checked every two or three hours 24 hours a day. Petitioner testified he was completely dependent on others to perform the most basic human functions.

The case was tried before an administrative law judge (ALJ). After trial, the ALJ affirmed the MCO’s decision, finding the “total Private Duty Nursing, Personal Care Assistance, and Self Direction total services limit is sixteen hours per day.”

The Director of the state Medicaid agency adopted the ALJ’s Initial Decision. The Director agreed with ALJ and found petitioner’s necessary personal care and household tasks could be accomplished within 105 hours per week and any additional hours would only be used for supervision or companionship which was not an authorized use of the service.  The Director concluded her written opinion by emphasizing that providing D.N. with 24 hours assistance under these circumstances “would be contrary to the purpose of the PCA program, which is intended to provide medically necessary assistance with specific health related tasks.” D.N. filed an appeal to the Superior Court of New Jersey, Appellate Division.

The appeals court held that it reviewed decisions of a State administrative agency like the Medicaid agency “under an arbitrary and capricious standard,” guided by three major inquiries: (l) whether the agency’s decision conforms with relevant law; (2) whether the decision is supported by substantial credible evidence in the record; and (3) whether, in applying the law to the facts, the administrative agency clearly erred in reaching its conclusion.

Guided by those principles of administrative review, the appeals court concluded that the Director’s decision to deny 24 hour per day PCA services to D.N. was arbitrary, capricious, and not supported by the evidence in the case. The court held that D.N. established that he needs 24 hours of PCA services based exclusively on his indisputable medical fragility and complete inability to perform the most basic functions without assistance from a PCA.

The case is attached here - D.N. v. Division of Medical Assistance and Health Services

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