State High Court Upholds Restrictions on Medi-Cal Benefits

The California Supreme Court on Thursday let stand an appellate ruling that allows the state to continue restricting Medi-Cal benefits to services it considers “medically necessary,” even when a physician disagrees.

The justices, over three dissents, refused to review a ruling last December by a state Court of Appeal in Sacramento upholding efforts by the Legislature to control costs of the $5-billion medical assistance program.

The appellate court, in a 2-1 decision, concluded that making doctors the “sole arbiters of medical necessity” would result in claims for reimbursement for services “limited only by the imagination of physicians.”

Thursday’s action came in a brief order denying review and noting that Justices Stanley Mosk, Allen E. Broussard and Marcus M. Kaufman had voted to hear a challenge to the appellate ruling--one vote short of the number required on the seven-member court.

Lynn S. Carman of San Rafael, attorney for a group of Medi-Cal recipients who brought the case to the justices, said the action would have a “very destructive” impact on the poor. An appeal to the U.S. Supreme Court is likely, he said.

At issue was a provision of state law limiting services to those “medically necessary to prevent significant illness, to alleviate severe pain, to protect life or to prevent significant disability.”

The statute was challenged by the Medi-Cal recipients on the grounds it unduly restricted assistance to low-income people and allowed the state to improperly “second guess” treating physicians, conflicting with the federal Medicaid Act. The state’s program was established under federal law and federal monies provide half of its funding.

Sacramento Superior Court Judge William A. White upheld the challenge in a ruling issued in 1983, saying that the determination of what was “medically necessary” should be left to the physician. State officials appealed the decision, contending that it would mandate significant changes in Medi-Cal procedures and cost the state about $118 million a year in lost savings. The restrictions remained in effect during the appeal.

On Dec. 9, the appellate court reversed White’s ruling, upholding the legality of the state’s limitations on Medi-Cal reimbursements.