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Case No. 18-0759

Willie Carroll
v.
Iowa Department of Human Services

Appellant

Willie Carroll

Appellee

Iowa Department of Human Services

Attorneys for Appellant

Judith R. Bӧes, Sarah K. Franklin, and Abhay M. Nadipuram

Attorneys for Appellee

Lisa Reel Schmidt, Assistant Attorney General

Court of Appeals

Court of Appeals Opinion

Opinion Number:
18-0759
Date Published:
Jun 19, 2019
Summary

            Appeal from the Iowa District Court for Polk County, Lawrence P. McLellan, Judge.  AFFIRMED ON APPEAL; REVERSED AND REMANDED ON CROSS-APPEAL.  Considered by Doyle, P.J., Mullins, J., and Mahan, S.J.  Opinion by Mullins, J.  (13 pages)

            Willie Carroll appeals, and the Iowa Department of Human Services (DHS) cross-appeals, a district court ruling on Carroll’s petition for judicial review partially affirming an agency determination and remanding the matter to the agency.  Carroll argues the district court erred in affirming the denial of four out of five of the skilled-nursing visits she requested to be covered by her managed-care organization because (1) the court failed “to consider whether the requested skilled nursing visits qualify as ‘restorative and maintenance home health agency services’” under Iowa Administrative Code rule 441-78.9, (2) DHS abused its discretion in using arbitrary criteria in denying the request, (3) the court erred in failing to find DHS’s decision’s negative impact on private rights is grossly disproportionate to the public interest, and (4) the factual determinations that skilled-nursing visits were not medically necessary are unsupported by substantial evidence.  On cross-appeal, DHS contends the district court erred in remanding the matter to the agency for the purpose of determining whether one of the five requested skilled-nursing visits was medically necessary.  OPINION HOLDS: Carroll has failed to preserve error on her claims concerning restorative and maintenance care, the criteria used by Amerigroup and DHS in denying the request for prior authorization, and gross disproportionality.  We find the agency determination affirming the denial of all five requested skilled-nursing visits is supported by substantial evidence.  We therefore affirm on appeal.  On cross-appeal, we reverse the district court’s remand of the matter to the agency, and we remand the matter to the district court for the entry of an order affirming the agency determination.

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