Fournier v. Sebelius

Denial of dental coverage for Medicare beneficiaries does not constitute a violation of beneficiaries’ right to equal protection under the Fifth Amendment when denial is based on reasonable interpretation by the Secretary of Health and Human Services of an ambiguous statute.

Berg and DiCecco both suffered from conditions that caused a loss of salivary function, causing dental problems that required costly services. Both were Medicare beneficiaries denied coverage first by the plan contractors, then an Administrative Law Judge ("ALJ"), and finally by the Medicare Appeals Council ("MAC"). They then joined in a suit in district court by Ronald Fournier to challenge MAC decisions. Fournier’s claim was dismissed as moot when he received a favorable ruling from an ALJ, but Berg and DiCecco continued with their challenge. The district court held that substantial evidence supported the Secretary’s decision, that the Secretary’s interpretation was reasonable, and that this denial did not violate appellants’ Fifth Amendment equal protection rights. The district court found that, under U.S.C. § 1395y(a)(12), where the primary qualifying procedure is non-dental, the dental procedure will be covered when performed by the same practitioner at the same time, but “routine” outpatient dental procedures are excluded from coverage by Medicare, despite the complexity of the procedure. On appeal, they argued that this interpretation of the statute did not carry out Congress’ intent and that this coverage policy was irrational. However, the Ninth Circuit held that, applying the test for deference from Chevron, U.S.A., Inc. v. Natural Res. Def. Council, Inc., the Secretary’s construction of the statutory exclusion was reasonable and should be afforded Chevron deference. To merit the Chevron level of deference, the Court applied the two-prong test from United States v. Mead Corp., finding that “Congress delegated authority to the agency generally to make rules carrying the force of law,” and that the interpretation was “promulgated in the exercise of that authority.” Further finding that included coverage did not create similarly situated “favored classes,” the Ninth Circuit upheld the district court’s denial of appellants’ equal protection claim. AFFIRMED.