Arizona Court of Appeals Division One Holds Dentures Are Medically Necessary Under AHCCCS When Dentist Determines Patient Has Inability to Chew Food.

Due to the rampant decay of her teeth, Bridget Sharpe’s dentist requested that AHCCCS approve the removal of all of her teeth and provide her with dentures.  AHCCCS approved the removal of her teeth, but denied her dentures because under AHCCCS regulations dentures are only “medically necessary” if there is a medical need beyond the inability to chew.  The Superior Court affirmed AHCCCS’s position and denied Sharpe dentures.

The Court of Appeals reversed and remanded with an order that Sharpe was entitled to dentures.  While the Court noted that it gives great weight to an agency’s interpretation of a statute, it also noted that an administrative rule cannot be inconsistent with or contrary to the statute it seeks to effectuate.   The Court also reaffirmed that AHCCCS’s rule-making authority did not allow it to eliminate coverage for an entire group of patients that would otherwise be covered.

The statute at issue, A.R.S. § 36-2907(A)(6), states that AHCCCS contractors “shall provide” “dentures ordered by a dentist” if they are “medically necessary.”  The AHCCCS director interpreted this statute by rule to require that a primary care provider, as opposed to a dentist acting alone, determine that dentures are necessary for the patient.  A.A.C. R9-22-201.  The Court held the statute specifically provided for “dentures ordered by a dentist.”  Therefore, the Court found that AHCCCS’s rule requiring a primary care provider, as opposed to a dentist, to determine that dentures are necessary is invalid as inconsistent with § 36-2907(A)(6).

 In addition, the AHCCCS director promulgated another rule that dentures are only “medically necessary” if there is a medical need for the dentures beyond the inability to chew.  Medical Policy 310.  The Court found this rule to be absurd, as the plain purpose of providing dentures is to restore the ability to chew to those who have lost their teeth.  Accordingly, the Court also found this rule to be invalid as inconsistent with § 36-2907(A)(6). 

Judge Barker authored the opinion, with Presiding Judge Brown and Judge McVey concurring