Green Hospital v. United States

23 Cl. Ct. 393, 1991 U.S. Claims LEXIS 238, 1991 WL 107057
CourtUnited States Court of Claims
DecidedJune 17, 1991
DocketNo. 90-310C
StatusPublished
Cited by6 cases

This text of 23 Cl. Ct. 393 (Green Hospital v. United States) is published on Counsel Stack Legal Research, covering United States Court of Claims primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Green Hospital v. United States, 23 Cl. Ct. 393, 1991 U.S. Claims LEXIS 238, 1991 WL 107057 (cc 1991).

Opinion

OPINION

LYDON, Senior Judge:

This case is before the court on the parties’ motions for summary judgment. The complaint seeks judicial review of a final agency decision denying plaintiff Green Hospital (Hospital) reimbursement for hospital services rendered to a beneficiary of the Civilian Health and Medical Program for the Uniformed Services (CHAMPUS), 10 U.S.C. § 1071 et seq1 Oral argument was held on May 2, 1991. For the following reasons, the court finds in favor of defendant.

I. INTRODUCTION

CHAMPUS is a health care and benefits program for dependents of present and former members of the uniformed services, established pursuant to the Dependents’ Medical Care Act, 10 U.S.C. § 1071 et seq. The Act authorizes the Secretary of Defense to contract with civilian sources for the medical care of dependents of service members. Pursuant to regulations promulgated under the Act, the administration of [395]*395CHAMPUS is delegated to the Director of the Office of CHAMPUS (OCHAMPUS). 32 C.F.R. § 199.5, 199.7.

CHAMPUS provides financial assistance to beneficiaries of health care services rendered by civilian health care facilities when such services are not available in military health care facilities. CHAMPUS regulations provide that, subject to all applicable definitions, conditions, limitations, and/or exclusions, CHAMPUS will share in the cost of services provided by civilian hospitals if the services are “medically necessary” and are required in the diagnosis and treatment of illness or injury. 32 C.F.R. § 199.10.

“Medically necessary” services are those “that are generally accepted by qualified professionals to be reasonable and adequate for the diagnosis and treatment of illness, injury, pregnancy, and mental disorders.” 32 C.F.R. § 199.8(b).

The regulations also provide that CHAM-PUS coverage excludes “[sjervices and supplies not provided in accordance with accepted professional medical standards; or related to essentially experimental or inves-tigational procedures or treatment regimens.” 32 C.F.R. § 199.10(g)(15).

The regulations define the term “experimental” in pertinent part as follows:

[Mjedical care that is essentially investigatory or an unproven procedure or treatment regimen (usually performed under controlled medicolegal conditions) which does not meet the generally accepted standards of usual professional medical practice in the general medical community____ [A]ny medical services or supplies provided under a scientific research grant, either public or private are classified as “experimental.” Use of drugs and medicines not approved by the Food and Drug Administration for general use by humans ... is also considered to be experimental____

32 C.F.R. § 199.8(b).

Under certain circumstances, health care services required to treat complications arising from noncovered procedures may be deemed a covered benefit. CHAMPUS regulations provide:

Benefits are available for otherwise covered services and supplies required in the treatment of complications resulting from a noncovered incident of treatment (such as non-adjunctive dental care, tran-sexual [sic] surgery, cosmetic surgery, etc.), but only if the subsequent complication represents a separate medical condition such as a systemic infection, cardiac arrest, acute drug reaction, etc. Benefits may not be extended for any subsequent care or procedures related to the complication that is essentially similar to the initial non-covered care. Examples of complications similar to the initial episode of care (and thus not covered) would be repair of facial scarring resulting from dermabrasion for acne or repair of a prolapsed vagina in a biological male who had undergone transexual [sic] surgery.

32 C.F.R. § 199.10(e)(9).

In 1985, autologous bone marrow transplants (ABMT) were considered “experimental” by CHAMPUS, according to a provision in the unpublished 1985 CHAMPUS Policy Manual, and thus were excluded from CHAMPUS coverage. In 1985, published CHAMPUS regulations did not contain any specific reference to the ABMT procedure. By contrast, the Policy Manual indicated that allogeneic bone marrow transplants were a covered service in 1985.

In autologous bone marrow transplants, a significant amount of the patient’s bone marrow is aspirated (removed by means of suction process), purged of leukemic cells, and frozen, while the patient is given extremely high doses of chemotherapy, which kills the cancer cells, as well as the patient’s remaining bone marrow. The patient's own bone marrow is then reinserted into the patient’s body, where it generally regenerates. In allogeneic bone marrow transplants, a matching donor is found to donate bone marrow to replace the marrow removed from the patient.

The 1985 Policy Manual provision, which excluded from coverage autologous transplants, explained that bone marrow purging was considered to be an investigational [396]*396procedure. Allogeneic bone marrow transplants, which do not involve purging, were not considered experimental in 1985. Green Hospital’s consent form for patients undergoing the autologous bone marrow transplant procedure warns of the possibility that purging and freezing procedures may prevent the patient’s bone marrow from regenerating, with potentially fatal consequences.

On May 1, 1987, CHAMPUS changed its policy by allowing payment of health benefits for autologous bone marrow transplants to treat certain diseases, and on November 1, 1987, CHAMPUS approved payment for the ABMT procedure to treat acute lymphocytic or lymphoblastic leukemia (ALL). Pursuant thereto, on October 6, 1988, CHAMPUS revised its policy manual to include coverage of ABMT procedures to treat ALL. However, the revised Policy Manual provision still indicated that coverage for bone marrow purging was investigational, and therefore was not covered.

II. THE CLAIM

The events that led to Green Hospital’s rendition of medical services to the CHAM-PUS beneficiary are as follows. In November of 1983, the beneficiary was put into a state of complete remission from ALL by chemotherapy treatment.2 In April of 1985, the 20-year-old beneficiary suffered a relapse and was put into second remission by additional chemotherapy. Adult acute lymphoblastic leukemia in second remission generally is fatal within a year. Believing that a bone marrow transplant would increase the beneficiary’s chances of survival, his attending physician at the Naval hospital where the beneficiary was receiving treatment recommended a bone marrow transplant.

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Bluebook (online)
23 Cl. Ct. 393, 1991 U.S. Claims LEXIS 238, 1991 WL 107057, Counsel Stack Legal Research, https://law.counselstack.com/opinion/green-hospital-v-united-states-cc-1991.