Hasner v. Western Oregon Advanced Health

“If a condition/treatment pair is not on the [Health Evidence Review Commission (“HERC”)] Prioritized List of Health Services and the Division determines the condition/treatment pair has not been identified by the HERC for inclusion on the list, the Division shall make a coverage decision in consultation with the HERC.” OAR 410-130-0200(10).

Petitioner sought judicial review of an ALJ’s determination to uphold a decision made by the Division of Medical Assistance Programs (DMAP) of the Oregon Health Authority that denied authorization for treatment at the request of her doctor. Petitioner argued that coverage should be determined by prior authorization and apply OAR 410-130-0200(10). DMAP argued the denial was proper the treatment was not “paired together” with the condition on the Prioritized List of Health Services. “If a condition/treatment pair is not on the [Health Evidence Review Commission (“HERC”)] Prioritized List of Health Services and the Division determines the condition/treatment pair has not been identified by the HERC for inclusion on the list, the Division shall make a coverage decision in consultation with the HERC.” OAR 410-130-0200(10). The Court of Appeals determined the ALJ’s decision did not conform with the administrative rule requirements because the denial of coverage was based on the condition and treatment not being paired on the Prioritized List of Health Services. Reversed and remanded.