Judge Rules that Medicaid Must Pay for Liver Transplant for Lambda Legal Client in Arizona who has HIV

(Phoenix, Friday, October 28, 2005) — Arizona’s Medicaid program has agreed to the findings of an administrative law judge who said the program must pay for a liver transplant for an Arizona woman who has HIV. “The judge’s ruling clears the way for our client to receive a life-saving liver transplant,” said Jen Sinton, HIV Project Staff Attorney at Lambda Legal. “We’re relieved that the judge saw that Medicaid’s decision to deny this woman a transplant was not based on good medicine or sound science, and that the director came to understand that this procedure for our client is medically necessary and desperately needed.” Brenda Gwin, a 49-year-old resident of Phoenix, was diagnosed with end-stage liver disease in November 2004 — a result of Hepatitis C. Since then her condition has deteriorated rapidly and in June of 2005 her doctors determined that she meets the criteria for liver transplantation.

That same month Mercy Care, one of the plans within the Arizona Health Care Cost Containment System (Medicaid), informed Gwin’s doctor that the request for coverage had been turned down because she has HIV. In light of the judge’s decision, AHCCCS has reversed course and will pay for the liver transplant. The judge held that, “It is clear that the evidence overwhelmingly favors the Complainant,” and AHCCCS’s director agreed, noting that “the requested transplant is medically necessary and not experimental.” The director also stated that the health plan “violated statute, regulation and/or general legal principle by denying Complainant’s request for authorization for the provision of a liver transplant.” “Our client now has an opportunity to receive a liver transplant that could save her life, and we urge AHCCCS to change its policy of automatically denying people with HIV transplants based solely on their HIV status,” Sinton said.

In its appeal, Lambda Legal cited a 2002 New England Journal of Medicine article on the subject that found “no evidence of poorer survival among otherwise healthy HIV-positive patients who are receiving anti-retroviral therapy,” which Sinton said is precisely Gwin’s situation. According to Lambda Legal, people with HIV are still sometimes blocked from being considered for transplants, even though medical and scientific evidence makes it clear that they should be evaluated on a case-by-case basis like any other transplant candidates. Last month, the governor of California signed a groundbreaking bill that says providers can’t deny organ transplantation based on HIV status alone. Lambda Legal is co-counsel on this case with attorney Srini Varadarajan of Community Legal Services in Phoenix.