In re Brenda Gwin

Administrative appeal of state Medicaid program’s refusal to cover cost of life-saving organ transplant because recipient the was a woman living with HIV

  • Status: Closed
  • Attorneys
    • Co-counsel/Cooperating Attorneys: Srini Varadarajan, Community Legal Services, Inc. in Phoenix.

Summary

Brenda Gwin was diagnosed with end-stage liver disease as a result of Hepatitis C.  Her condition was deteriorating rapidly and her doctors determined that she met the criteria for and needed a liver transplant. Mercy Care, one of the providers within the Arizona Health Care Cost Containment System (Arizona's Medicaid program), informed Gwin's doctor that the request for coverage had been turned down because she was HIV-positive. AHCCCS refused to fund organ transplants for anyone infected with the HIV virus because it claimed that HIV was a contraindication for a transplant. Lambda Legal filed an administrative appeal on behalf of Gwin arguing that people with HIV should be evaluated on a case-by-case basis like any other transplant candidates. The AHCCCS Director agreed. As a result of his decision, AHCCCS agreed to reimburse the cost of Gwin's transplant. After that decision, Lambda Legal continued to advocate with AHCCCS to achieve a change in its policies governing coverage of organ transplants.

Context

Many people living with HIV can safely receive organ transplants, yet, even in cases where a transplant is medically necessary and life-saving, HIV-positive people are often denied transplants or insurance coverage for medically necessary transplants. Both the federal Rehabilitation Act and the Americans With Disabilities Act protect people with disabilities, including HIV, from being denied the benefits of medical assistance programs based on their disability. In addition, under federal and Arizona law, Arizona's Medicaid program must cover liver transplants that are medically necessary. 

Lambda Legal's Impact

Following the ruling, AHCCCS agreed to use state funds to pay for Gwin's liver transplant, and it revised its policies regarding the eligibility of people with HIV for transplants. This is one of many Lambda Legal cases to ensure that people with HIV have fair and equal access to medical care and other key services.

History

  • June 2005 Gwin is denied a liver transplant.
  • September 2005 Administrative hearing challenging the denial is held.
  • October 2005  Administrative Law Judge rules that Arizona's Medicaid program must pay for Gwin's transplant and program Director accepts that decision.