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Court holds that Maine Department of Health and Human Services wrongfully denied healthcare benefits to 14 year old girl

On December 20, 2012, the Maine Employee Rights Group (MERG) secured an important victory for its 14 year old client, Alathea Bushnell. Alathea sought MERG’s assistance because Maine’s Department of Health and Human Services (DHHS) had denied Mainecare coverage for nursing services that she needed due to an uncontrolled seizure disorder. On a daily basis, Alathea can experience anywhere from 0 to 150 seizures. The seizures vary in severity but it is not uncommon for her to experience “grand mal” seizures. During these grand mal seizures, she has injured herself, turned blue in the face, and foamed at the mouth. Due to this seizure disorder, she must wear a helmet at all times.

DHHS’s Commissioner, Mary Mayhew, denied coverage for the nursing services Alathea’s doctors said that she needed even though Maxim Health Care, an authorized agent for the State, as well as a DHHS appeal hearing officer both determined that she needed the nursing services. The Commissioner reasoned that DHHS did not have to provide coverage for these nursing services because Alathea’s condition was not “unstable.” The Court determined that the Commissioner erred in denying benefits for the nursing care because she failed to properly consider what care was “reasonable and necessary to manage [Alathea’s] condition.”