JACK C. SNEDEKER v. STATE HEALTH BENEFITS COMMISSION

 

NOT FOR PUBLICATION WITHOUT THE

APPROVAL OF THE APPELLATE DIVISION

SUPERIOR COURT OF NEW JERSEY

APPELLATE DIVISION

DOCKET NO. A-2019-04T32019-04T3

JACK C. SNEDEKER,

Appellant,

v.

STATE HEALTH BENEFITS

COMMISSION,

Respondent.

______________________________________

 

Argued February 16, 2006 - Decided March 9, 2006

Before Judges Conley, Weissbard and Winkelstein.

On appeal from the State Health Benefits Commission.

Katherine Benesch argued the cause for appellant (Duane Morris, attorneys; Ms. Benesch, of counsel; Ms. Benesch and Susan Okin Goldsmith, on the brief).

David Dembe, Deputy Attorney General, argued the cause for respondent (Zulima V. Farber, Attorney General, attorney; Patrick DeAlmeida, Assistant Attorney General, of counsel; Mr. Dembe, on the brief).

PER CURIAM

Plaintiff, whose twenty-four year old comatose son, Michael, requires around-the-clock care, appeals a final administrative determination by the State Health Benefits Commission (SHBC) concluding that in-home care provided by a private-duty nurse from March 1, 2002, to October 31, 2003, was not covered under the State Health Benefits Plan. As a result, plaintiff is currently responsible for the cost of those services for that period of time. That cost is $360,000. We remand for further proceedings.

For the most part, this is not a factually disputed matter. Neither the parties, nor their respective doctors, dispute that Michael, who nearly drowned when he was two years old, suffered a severe and irreversible anoxic brain injury. As a result, he is a spastic quadriplegic in a Level II coma, with respiratory insufficiency. He is fed through a gastric tube, has no gag reflex and cannot swallow. It is undisputed that he requires around-the-clock care.

Health insurance coverage is provided for plaintiff's family through the Township of South Brunswick, for whom plaintiff worked until his retirement. Until March 2002, the Township's health insurance for its employees was provided through private insurance companies which paid for Michael's in-home nursing care. That care was provided by Maxim Healthcare Services and consisted of in-home private-duty licensed nursing care sixteen hours a day, seven days a week. Plaintiff and his wife provided the remaining eight hours of care each day.

In March 2002, the Township changed its coverage to the Traditional Plan provided by the State Health Benefits Program (SHBP), pursuant to the New Jersey Health Benefits Program Act (Act), N.J.S.A. 52:14-17.25 to -.45. That plan is administered by Horizon Blue Cross Blue Shield. It declined to cover the in-home nursing care and the SHBC agreed. Ultimately, in October 2003, coverage was obtained under a Medicaid waiver.

The SHBC is created by statute and entrusted with the responsibility of establishing and administering a health benefits program for those public employers and their employees who choose to participate in the program. The purpose of the SHBP is to provide "comprehensive health benefits for eligible public employees and their families at tolerable cost." Heaton v. State Health Benefits Comm'n, 264 N.J. Super. 141, 151 (App. Div. 1993). Thus, the SHBC is charged with negotiating contracts that provide health coverage "on such terms as it deems to be in the best interests of the State and its employees . . . ." N.J.S.A. 52:14-17.28. The minimum level of benefits these contracts may provide is statutorily mandated. N.J.S.A. 52:14-17.29(A). The statutorily required benefits do not expressly include in-home private-duty nursing care.

In furtherance of the Legislative intent to provide health coverage at a "tolerable cost," the Act authorizes SHBC to provide such limitations and exclusions upon benefits contracted for "as the [SHBC] finds to be necessary or desirable to avoid inequity, unnecessary utilization, duplication of services or benefits otherwise available, . . . or for other reasons." N.J.S.A. 52:14-17.29(B). We have explained in Murray v. State Health Benefits Comm'n, 337 N.J. Super. 435 (App. Div. 2001):

The Commission was established by N.J.S.A. 52:14-17.25-[.]45, the New Jersey State Health Benefits Program Act, to administer a program providing comprehensive health care benefits for eligible public employees, retirees and their dependents at reasonable cost. The Commission is composed of the State Treasurer, the Commissioner of Insurance and the Commissioner of Personnel. N.J.S.A. 52:14-17.27. The Commission has entered into a contract with Blue Cross Blue Shield to administer the traditional plan. Previously, Prudential Insurance Company administered the traditional plan. Neither Blue Cross Blue Shield nor Prudential acts as insurers; rather, the State self-insures the cost of the traditional plan, and the plan administrator reviews and pays claims according to the plan. The Commission pays an administrative fee and reimburses the administrator for paid claims. The Commission retains final authority and financial responsibility for the State Plan.

The traditional plan . . . is described in a booklet entitled "New Jersey State Health Benefits Program Medical Plans Information Handbook." The Commission has statutory authority to establish "such limitations, exclusions, or waiting periods as the commission finds to be necessary or desirable to avoid inequity, unnecessary utilization, duplication of services or benefits otherwise available . . . ." N.J.S.A. 52:14-17.29(B). The Commission's contract with Blue Cross Blue Shield establishes the types of services and supplies that are covered as eligible services. Under N.J.A.C. 17:9-2.16, the Commission has adopted by reference all of the policy provisions in the contract "to the exclusion of all other possible coverages." No benefits may be paid unless they are "stipulated in the contracts held by the [Commission]." N.J.S.A. 52:14- 17.29(B).

Under the contract, the traditional plan pays only eligible charges. . . . Furthermore, we explained in Heaton v. State Health Benefits Comm'n, 264 N.J. Super. 141, 151 (App. Div. 1993), that the State Plan was not to be considered a commercial insurance policy. The Commission must balance its obligations of meeting the health care needs of its members with a fiduciary obligation to make the program cost effective. Consequently, interpretation of the State Plan provisions is not approached as if we were analyzing language in commercial insurance policies. Any ambiguous provisions in the State Plan will not be construed against the State as a contract of adhesion, which is the approach taken with commercial policies.

[Id. at 439-40.]

As the Handbook covering the Traditional Plan clearly states, the Traditional Plan is self-funded. Payment of claims and services comes from funds supplied by the State, participating local employers and the members.

The Traditional Plan has three parts: basic benefits, extended basic benefits, and major medical benefits. The Plan generally describes these three parts thusly:

BASIC BENEFITS

Basic benefits cover certain hospital (or facility) charges, in full, as follows:

- Inpatient covered services at an approved acute care hospital.

- Services provided at a skilled nursing facility or detoxification facility.

- Services of salaried staff, including doctors, nurses, interns, and others.

- Supplies such as drugs, X-rays, bandages, oxygen, and laboratory/pathology services.

Outpatient covered serves billed by an approved facility include:

- Facility charges for the treatment of accidental injuries.

- Dialysis.

- Facility charges for a covered surgical procedure.

- Application and removal of casts.

- Alcohol treatment.

- Home health care.

- Facility charges for same-day surgical centers.

EXTENDED BASIC BENEFITS

Extended basic benefits cover certain medical-surgical or professional charges billed by an eligible provider and may include items such as surgical and anesthesia fees, X-rays, laboratory tests, and inpatient medical care. Services are reimbursed according to a fee schedule and are not subject to deductibles and/or coinsurance.

Basic benefits and extended basic benefits are either paid in full or according to a fee schedule on a first-dollar basis. That is, there is no deductible or required coinsurance and the first dollars paid against the claim come from the plan, not the member. If basic or extended basic benefits do not completely pay for an eligible charge, the remainder of the charge, with some exceptions, is then normally processed under the major medical portion of the plan.

MAJOR MEDICAL BENEFITS

Major medical benefits include eligible services not completely paid under the basic and extended basic benefits, such as rehabilitation hospital care, outpatient treatment, prescription drugs, and doctor's office visits. Generally, eligible expenses are paid at 80 percent of "reasonable and customary allowances" after you satisfy an annual deductible. A reasonable and customary allowance is the maximum amount considered eligible for payment for a specific service under the plan. . . .

Plainly, then, not all health needs are covered by the Plan. The Handbook expressly sets forth the following as "General Conditions of the Plan":

The plan will pay only for eligible services or supplies, which:

- are medically needed at the appropriate level of care for the medical condition . . .;

- are listed in the "Eligible Services and Supplies" sections of this handbook;

- are ordered by a doctor . . . for treatment of illness or injury;

- were provided while you and your eligible family members were covered by the plan. . . . ;

- are not specifically excluded (listed in the section "Charges Not Covered by the Plan" . . .).

There is no dispute here that the services provided Michael for the period in question were medically needed. But the Plan also requires that they be listed in the "Eligible Services and Supplies" sections of the Handbook, and not be "specifically excluded."

In addition, and pertinent to the dispute here, the "General Conditions" section of the Handbook includes the following:

Maintenance or Supportive Care

The Traditional Plan does not provide coverage for services that are determined to be for maintenance or supportive care. Maintenance care is defined as care given to reduce the incidence or prevalence of illness, impairment and risk factors and to promote optimal function. Maintenance treatments are considered to be not medically needed and are, therefore, not eligible for coverage. Supportive care is defined as treatment for patients having reached maximum therapeutic benefit in whom periodic trials of therapeutic withdrawals fail to sustain previous therapeutic gains. In some instances chiropractic care or physical therapy may be clinically appropriate (such as treatment of a chronic condition that requires supportive care) yet it would not be eligible for reimbursement under the Traditional Plan.

We first look to the sections which set forth those services that qualify as "eligible services" to see if in-home private-duty nursing care is an eligible service. Included in the basic benefits section captioned "Other Hospital Services," and under the subsection for "Home Health Care Agency Benefits," is the following:

The hospitalization portion of the Traditional Plan covers home health visits as long as the circumstances meet plan guidelines. Members receiving home health care must be home-bound and must require skilled nursing care, physical therapy, or speech therapy under a plan prescribed by an attending physician and approved by Horizon BCBSNJ. Eligible home health services provided by an approved participating home health agency include:

- Part-time skilled nursing services provided by or under the supervision of a registered professional nurse (RN).

This would seem to authorize Michael's in-home, private-duty nursing care as an eligible service. However, this section of the Plan continues:

Up to 60 visits are available within 61 days per occurrence. Every three home health care visits by participating Horizon BCBSNJ home health care agency reduces your available inpatient days by one (1). A prior inpatient hospital stay is not required to qualify for home health agency benefits, however, your provider must contact CareAdvantage, Inc. at 1-800-624-1294 in order to certify benefits through a participating agency prior to services being rendered. Benefits are not available for services rendered by a non-participating home health care agency.

Home health care services that are deemed "custodial" by Horizon BCBSNJ will not be eligible for benefits under the Traditional Plan. Custodial services are primarily services rendered that do not require the skill level of a nurse for performance. These services include but are not limited to activities of daily living (ADLs); such as bathing, meal preparation, dressing, feeding, aiding in [movement], cleaning, and laundry functions.

These limitations, in part, reduce the coverage for in-home nursing care to "[u]p to 60 visits . . . within 61 days per occurrence." Since the SHBC does not rely upon this limitation, we assume it is not pertinent. But the second limitation, i.e. "custodial" in-home nursing care, is pertinent. Pursuant thereto, care that does not require the "skill level of a nurse," such as "bathing, meal preparation, dressing, feeding, aiding in [movement], cleaning, and laundry functions," does not qualify as in-home private nursing care under the basic benefits section.

In-home private-duty nursing care is not included as an eligible service in the "extended basic benefits" section. But it is an eligible service included in the "Major Medical Benefits" section. Specifically, that portion of the Plan states:

The following services are included under the major medical portion of the Traditional Plan.

. . . .

- Private duty professional nursing under very strict standards. Private duty nursing must be ordered by a doctor and provided by a registered nurse (R.N.) or a licensed practical nurse (L.P.N.) other than you, your spouse, or a child, brother, sister, or parent of you or your spouse. Private duty nursing will only be covered under extraordinary circumstances upon evidence of a clear and convincing objective need. Private duty nursing coverage will not be covered if the care is[:]

- custodial care (or assistance in the activities of daily living in a home, hospital or facility of any kind); or

- normally provided by or should be provided by hospital nursing staff; or

- rendered by or could be provided by home health aides or any other nurses aides.

In still another portion of "Eligible Major Medical Services" section, the limitations upon eligible private-duty nursing care are repeated:

Private Duty Nursing

Private duty professional nursing is only available under very strict standards. Private duty nursing will only be covered under extraordinary circumstances upon evidence of a clear and convincing objective need.

Private duty nursing must be ordered by a doctor; and provided by one of the following:

- Registered nurse (R.N.), other than you, your spouse, or a child, brother, sister, or parent of you or your spouse.

- Licensed practical nurse (L.P.N.), other than you, your spouse, or a child, brother, sister, or parent of you or your spouse.

Private duty nursing will not be covered if the care is:

- the type of care normally provided by or that should be provided by hospital nursing staff;

- rendered by or could be provided by home health aides or any other nurses' aides; or

- custodial care or assistance in the activities of daily living in a home or facility of any kind.

Without question, then, the Plan does provide for private- duty nursing care as an eligible service, both under its basic benefits section and its major medical section. But the scope of coverage is limited. Critical to this dispute, nursing care which is custodial, i.e. bathing, meal preparation, dressing, aiding in movement, cleaning, laundry functions and the like, is not an "eligible service."

Beyond the limitations imposed by way of the delineations of what services and care qualify as "eligible services," the Handbook expressly sets forth "Charges Not Covered by the Plan." Specifically excluded are "maintenance treatment" and "supportive care." The exclusion for maintenance treatment explains:

Frequently, treatment (i.e., chiropractic care and physical therapy)for a chronic condition, such as a bad back, reaches a plateau. That is, treatment brings a member to a point when further treatment cannot be reasonably expected to improve the diagnosed condition. Instead it maintains the member's current condition. When such a point is reached, further treatment is deemed to be maintenance care and is no longer eligible for coverage.

The exclusion for supportive care explains:

supportive care is defined as treatment for patients having reached maximum therapeutic benefit in whom periodic trials of therapeutic withdrawals fail to sustain previous therapeutic gains. In some instances chiropractic care or physical therapy may be clinically appropriate (such as treatment of a chronic condition that requires supportive care) yet it would not be eligible for reimbursement under the Traditional Plan.

The exclusion section of the Handbook also refers to care which is "primarily" custodial. We pause here to comment on this exclusion. Both the ALJ and the SHBC focused upon the modifier "primarily." But here, the tasks performed by the nurses during their sixteen-hour shift were not mixed in their nature. There were discrete tasks of skilled nursing care performed and there were also discrete tasks of nonskilled nursing care performed. There is nothing primary or secondary about these tasks. They either are covered nursing tasks or noncovered custodial/maintenance/supportive tasks.

In rejecting plaintiff's claim, Horizon initially disputed the medical necessity of the care provided and also considered it custodial, maintenance and/or supportive in nature. Thus, after the dispute was referred to the Administrative Law Judge (ALJ), the focus of the evidence was upon what the nurses did for Michael during the daily sixteen-hour shift. As we have said, there is no dispute that all of the care was medically necessary. The dispute was whether it was custodial, maintenance and/or supportive. In this respect, plaintiff's experts agreed that some of the care provided was custodial, maintenance and/or supportive. However, the "skilled" care tasks were not. Those tasks were depicted as the deep suctioning of Michael's airways, the periodic monitoring of his condition, including reading his oxygen levels, the gastric tube feeding and the provision of medications. One of SHBC's experts opined that that aspect of the sixteen hour care comprised 20% to 30% of the care, the other said it totaled one hour. In supplemental materials submitted in response to the ALJ's inquiry concerning the apportionment of the care, plaintiff submitted a breakdown from Maxim that reflects 87% of the sixteen hours constituted skilled nursing care.

In the end, though, the ALJ concluded that none of the care was ineligible as it was not maintenance, supportive nor "primarily" custodial. The focal premise of his conclusion that the care was neither maintenance nor supportive was that it was medically necessary. His rationale for rejecting the custodial exclusion was:

While undoubtedly a portion of the activities carried out by skilled nurses do fall within the ambit of "activities of daily living," the across-the-board sweep ofall services provided to [Michael] by these personnel into the "custodial" category is completely unwarranted.

[Emphasis added.]

We pause here to observe that this would seem to be an accurate reading of the custodial care provisions as applied to the discrete tasks performed by the nurses.

In any event, the SHBC disagreed with the ALJ's view that the Handbook's maintenance and supportive care exclusions are not applicable to medically needed care, pointing out that medical necessity was only one of the Plan's "General Conditions". Consistent with the express language of the Plan, even if care is considered medically necessary, it still is not covered if it is not an included "eligible service" and/or falls within the express exclusions. The SHBC did not deny that in-home nursing care can be an eligible service. But it concluded the care here fell within the maintenance and supportive care exclusion and was "primarily" custodial. As we have pointed out, the focus upon the word "primarily" in the custodial exclusion is really not applicable here as none of the various nursing tasks performed during the sixteen-hour shift can be considered mixed nursing/maintenance/supportive/ custodial care.

The dispute between the ALJ and the SHBC is not factual, but rather concerns an interpretation of the Plan's provisions. In this respect, the SHBC owed no deference to the ALJ's interpretation. On the other hand, we do owe the SHBC some deference to its interpretation, Matturi v. Bd. of Trs., Judicial Ret. Sys., 173 N.J. 368, 382 (2002), but not if that interpretation is not consistent with the applicable statutory and/or regulatory scheme. Heaton v. State Health Benefits Comm'n, supra, 264 N.J. Super. at 153. Cf. Green v. State Health Benefits Comm'n, 373 N.J. Super. 408, 419 (App. Div. 2004) ("If the Plan allows Horizon and the SHBC to make a cost-benefit analysis in deciding whether to pay for a home health aide and in certain cases . . . then it is [their] obligation to make that analysis . . . not to simply assert peremptorily that they do not pay for this service.").

Here, the focus of the SHBC, as it was of the ALJ, was upon the skilled nursing tasks. The plain language of the maintenance and supportive care exclusions simply does not fit those tasks. The Handbook defines maintenance care as "care given to reduce the incidence or prevalence of illness, impairment and risk factors and to promote optimal function." As further explained in the specific exclusionary language, it is "treatment . . . for a chronic condition, such as a bad back, [which has] reach[ed] a plateau . . . it maintains the member's current condition. . . . " Similarly, supportive care is defined as "treatment for patients having reached maximum therapeutic benefit . . . (such as treatment of a chronic condition that requires supportive care) . . . ."

In viewing the skilled nursing care tasks here as maintenance and/or supportive, then, the SHBC saw the issue as whether the care simply kept Michael at a stable level with incidental, periodic intervention of skilled nursing care needed, but without hope of improvement in his underlying injury-caused condition. That is the driving rationale for its rejection of the ALJ's decision, as it is the driving force behind the maintenance and supportive care exclusions. To be sure, limiting coverage to health care that is active treatment of an injury as opposed to passive, palliative treatment would be within the authority of the SHBC and consistent with the overall tenor of the Handbook.

But what troubles us is the undisputed fact that the "interventions" of the skilled nursing care, on this record, are required to treat life-threatening episodic conditions of deterioration of Michael's injury that may occur during the day. The interventive skilled nursing care simply does not fit the maintenance and supportive care provisions. Neither, clearly, is it custodial, primarily or otherwise. Such care is a specifically enumerated covered benefit.

But that does not end the inquiry. As we see it, the circumstances here involve a number of discrete tasks, some of which are covered and some of which are not. After the close of the hearing, the ALJ thought that might be the case. He wrote counsel:

In drafting the decision on this case and considering possible outcomes, I have some question as to how, as a practical matter, the parties would treat a decision which, if accepted by the Commission, determined that the blanket rejection of the $360,000 in charges was not sustainable, but nevertheless recognized that some portion of the services provided are indeed "custodial" in nature. While I have drawn no definite conclusions, I can posit that, if the Commission's present position that the care constituted "maintenance" and/or "supportive" care is essentially rejected, it would nevertheless be foolhardy to suggest that the skilled personnel did not also engage in "custodial" activities, as I suspect is probably true in many instances where nurses, otherwise providing clearly medically necessary care, also carry out functions which address elements of day-to-day living activities. Thus, while I suppose that if the decision were significantly favorable toward the petitioners, the insurer might simply pay the entire amount, perhaps, alternatively, some compromise would be reached that would exclude a portion of the total amount, recognizing that it covers a custodial care element. I do not profess to know what the normal procedure, if any, may be with regard to such a division of total costs, even where it is generally conceded by the insurer that coverage for services of skilled personnel would be appropriate. Therefore, I am turning to you for your thoughts on the matter, so that I can incorporate them in my ultimate thinking as to how this case would be brought to conclusion. In the end, I might conclude that no coverage is involved, but should I conclude that coverage is required, I am unsure whether the decision should simply order full payment. I doubt that it is practical to break down the final amounts in any simple fashion. But I will certainly consider your input.

In response to that, plaintiff maintained his position that all of the care was medically necessary and that that should be the end of the inquiry. But he offered:

In the case of Michael Snedeker, the nurses from Maxim Healthcare have estimated the amount of time they spend that might possibly be considered custodial care. Their estimate is that approximately twelve and one half percent (12.5%) of the care rendered might be considered custodial (activities of daily living), and that at least eighty-seven and one half percent (87.5%) is life-sustaining skilled nursing care. To arrive at this estimate, the nurses reviewed the skilled nursing tasks ordered by Dr. Ramadan on the Plan of Care (Exhibit P-9), and determined that the care rendered to Michael Snedeker for 14 of the 16 hours per day requires non-custodial skilled nursing services. (See Plan of Care Analysis, attached hereto).

The attached "Plan of Care Analysis" is as follows:

Skilled Nursing Task

______________________________

Nursing Assessment (full body): 1 hr. twice per day

Hours

____________________

2.0

Preparation of Meds, check G-Tube Placement, and administer meds via G-Tube: .5 hrs. 4 times a day

2.0

GT feedings: .5 hrs. 3 times per day

1.5

GT Site care: .5 hrs. 1 time per day

0.5

Preparation, administration of Nebulizer Treatments, Lung Assessment, Chest PT, suction related to Chest PT: 1 hr. 4 times per day

4.0

PRN Suctioning

2.0

Nursing documentation for chart: 1 hr. 2 times per day

2.0

TOTAL

14 of 16 Hours = 87.5%

The SHBC responded that "even if a portion of the care rendered to Michael is skilled, the totality of the care is still excluded," pointing to its experts' testimony, one of whom opined that 20% to 30% was noncustodial, and the other that one hour was noncustodial. The response, further, stated "the handbook clearly explains that once a person reaches a maximum medical improvement for the condition, coverage ceases."

As to the later contention, nowhere does the Handbook explain what is meant by "maximum medical improvement" or clearly state that once that condition is reached no further coverage will be provided. As to the SHBC's experts' assessment of what constituted covered skilled nursing care and what did not, it is plain from a reading of their testimony that both opinions were no more than speculation. On the other hand, plaintiff's supplemental evidence as to the actual time spent performing the discrete tasks was not offered during the hearing and, thus, the SHBC had no opportunity to confront it.

We are convinced that under the particular circumstances here the disputed sixteen hour a day care given to Michael constitutes both covered and noncovered care. That is to say, the care delineated in the supplemental submission of plaintiff as skilled nursing care would be covered. The remainder would not. Whether the times spent on the discrete tasks set forth in that submission are accurate, however, was not resolved by either the ALJ or the SHBC. At the most, in that respect, the SHBC offered as a footnote in its decision:

Petitioner's proffer [as to the apportionment of covered vis- -vis noncovered services], made in a post hearing letter to the ALJ, is based upon facts not in the record and is not part of the Exhibit List.

That may be so, but it was evidence requested by the ALJ and, presumably, considered by him, albeit he choose not to resolve the issue in his decision.

Reversed and remanded. On remand such supplemental proceedings as are deemed necessary for determining an apportionment of the covered and noncovered care consistent with this opinion shall be conducted by the ALJ, with an initial decision submitted to the SHBC for its final administrative determination consistent with the Administrative Procedure Act. We do not retain jurisdiction.

 

For some reason, the SHBC's reasoning as to this focused upon the fact that the ALJ did not cite the introductory language in the "General Conditions" portion of the Plan, i.e., "[t]he Plan will pay only for eligible services or supplies, which . . . " and criticized him for that. But the plain fact is, the specific listed conditions following the "noncited" language require such compliance as a condition. Those conditions were cited by the ALJ.

We pause here to note the sentence contained in the definition of maintenance care located in the "General Conditions" section of the Handbook that "[m]aintenance treatments are considered to be not medically needed and are therefore, not eligible for coverage." It is this sentence that the ALJ focused upon, construing it to mean that care which is medically needed cannot be maintenance care. Thus, in considering the exclusion for such care the SHBC focused upon that construction, with which it disagreed. We cannot fault the SHBC for that disagreement. Clearly the sentence means no more than if care falls within the definition of maintenance care the SHBC has determined that it is not eligible for coverage, regardless of whether it may be thought to be medically needed.

(continued)

(continued)

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A-2019-04T3

March 9, 2006