Massachusetts Board Orders Medicaid HMO to Cover Liver Transplant for HIV-Positive Man
In possibly the "first ruling of its kind" in the nation, a Massachusetts Medicaid appeals board yesterday ruled that an insurer that covers Medicaid beneficiaries must pay for a liver transplant for a man with HIV and end-stage liver disease, the Boston Globe reports. The decision comes just months after a separate state agency ruled that the same insurer, Neighborhood Health Plan, did not have to cover a liver transplant for an HIV-positive woman who was insured privately, not through Medicaid (Arnold, Boston Globe, 11/15). The Division of Medical Assistance Board of Appeals ruled yesterday that despite some scientific uncertainty about whether HIV reduces a transplant's recipient chances of survival, the procedure is "medically necessary" and not "experimental" (AP/Boston Herald, 11/14). The board's decision cited 14 successful liver transplants conducted since 1997 in which HIV-positive people were cured of their liver problems and saw "no worsening of their HIV status"; two of these individuals died for "reasons unrelated to HIV" (Boston Globe, 11/15). Under the ruling, the unidentified 41-year-old man, who also has hepatitis C, can now be referred to the University of Pittsburgh's transplant program, where he will go on a waiting list (AP/Boston Herald, 11/14). Should the center deem the man medically eligible for the transplant, Neighborhood Health will have to pay for the procedure (Pope, AP/Newsday, 11/14). The procedure can cost $300,000 or more (Boston Globe, 11/15).
A Distinction Between Medicaid and Private Insurance
This summer, Neighborhood Health, an affiliate of Harvard Pilgrim Health Care, denied coverage of a liver transplant to Belynda Dunn -- an HIV-positive woman with hepatitis C who was privately insured -- after stating that liver transplants in HIV patients were considered experimental. Dunn then appealed to the state Office of Patient Protection, which oversees private insurers. After the agency sided with Neighborhood Health, Dunn appealed the decision to federal court, but then withdrew her suit after a fundraising campaign brought in enough money to pay for her transplant (Boston Globe, 11/15). She is currently on the waiting list at the Pittsburgh transplant center (Lasalandra, Boston Herald, 11/15). Richard McGreal, a spokesperson for the Division of Medical Assistance, which runs MassHealth, the state's Medicaid and CHIP programs, said that yesterday's ruling was not a "blanket" decision for all Medicaid beneficiaries and the state would evaluate transplant candidates on a case-by-case basis. "Just because this person fits the medical necessity definition and is approved for a liver transplant, the next person who comes along may be totally different," he said (AP/Newsday, 11/14). Nevertheless, attorney Bennett Klein of Gays and Lesbians Advocates and Defenders said that the state's decision could motivate other states and private insurers to cover liver transplants for HIV-positive individuals. "Certainly, for all Medicaid recipients, HIV status alone can no longer be a basis to refuse liver transplantation. In that sense, this decision really breaks new ground," he said (AP/Boston Herald, 11/14).