This opinion will be unpublished and

may not be cited except as provided by

Minn. Stat. ß 480A.08, subd. 3 (1998).

 

STATE OF MINNESOTA

IN COURT OF APPEALS

C9-99-1774

 

 

Margaret Schmidtke,

Respondent,

 

vs.

 

Minnesota Department of Human Services, et al.,

Appellants.

 

Filed April 25, 2000

Affirmed

Anderson, Judge

 

 

Cass County District Court

File No. C2981155

 

 

Kathleen R. Hagen, Minnesota Disability Law Center, 430 First Avenue N., Suite 300, Minneapolis, MN55401 (for respondent)

 

Nancy E. Lamo, McCollum, Crowley, Vehanen, Moschet & Miller, Ltd., 1300 Norwest Financial Center, 7900 Xerxes Avenue South, Bloomington, MN55431 (for appellant)

 

††††††††††† Considered and decided by Schumacher, Presiding Judge, Peterson, Judge, and Anderson, Judge.

 

 

 

 

U N P U B L I S H E D†† O P I N I O N

ANDERSON, Judge

††††††††††† Appellant challenges the district court judgment reversing a decision by the Commissioner of Human Services (commissioner).The district court found that the commissionerís decision was not supported by substantial evidence.Because the guidelines established by the International Society for the Study of Dissociation are the present prevailing community standard for treating Dissociative Identity Disorder, and respondentís physicianís treatment plan is the most cost effective plan for treating respondentís disorder, we affirm.††

FACTS

††††††††††† In 1995, respondent Margaret Schmidtke began psychotherapy treatment for Dissociative Identity Disorder (DID), also known as Multiple Personality Disorder.In November 1996, respondentís physician, Dr. Ostrom, requested approval for 74.5 hours of treatment for respondent from Behavioral Health Services, Inc. (BHSI) for the 1997 treatment year.[1]BHSI approved 57 hours of treatment.Dr. Ostrom then requested 70 hours of treatment for respondent for the 1998 treatment year; BHSI approved 26 hours of treatment.Dr. Ostrom requested that BHSI internally review both of the decisions granting less treatment time than requested for 1997 and 1998.†† BHSI reviewed Dr. Ostromís documentation in support of increased treatment, but determined that Dr. Ostrom did not show that respondent needed the intensity of services he requested.

††††††††††† After BHSI declined to approve Dr. Ostromís request for treatment hours during the internal review, respondent sought an evidentiary hearing from appellant, the Minnesota Department Human Services (DHS).Dr. Ostrom testified at the hearing on behalf of respondent and explained that he based his treatment approach on treatment guidelines developed by the International Society for the Study of Dissociation (ISSD).But Dr. Ostrom requested less than one-half of the treatment sessions recommended by the guidelines.At the hearing, Dr. David Siegel testified on behalf of DHS and BHSI.Dr. Siegel criticized the ISSD guidelines because they are not based on empirical research or outcomes.

†† †††††††† After hearing the evidence, the appeals referee held that respondent had failed to show that Dr. Ostromís treatment plan was medically necessary.[2]Specifically, the referee held that respondent failed to show that Dr. Ostromís treatment plan, based on ISSD guidelines, was the prevailing community standard for treating DID.The referee also held that respondent failed to show that Dr. Ostromís treatment plan was the most cost effective treatment available. The Commissioner of Human Services (commissioner) adopted the refereeís findings of fact, conclusions of law and order.Respondent then filed a Request for Reconsideration with the DHS.The DHS reviewed respondentís request, found no factual or legal errors, and affirmed the commissionerís decision.Respondent then sought district court review of the commissionerís decision.The district court reversed, concluding that the commissionerís decision was not supported by substantial evidence.††

D E C I S I O N

 

††††††††††† This court does not defer to the district courtís appellate review of an administrative agencyís decision.Johnson v. Minnesota Depít of Human Servs., 565 N.W.2d 453, 457 (Minn. App. 1997).Instead, this court ďindependently examines the agencyís record and determines the propriety of the agencyís decision.ĒId.Our review of a decision of the Commissioner of Human Services (commissioner) is governed by Minn. Stat. ß 14.69 (1998).Kaplan v. Washington County Community Soc. Servs., 494 N.W.2d 487, 489 (Minn. App. 1993).This court may reverse an agency decision if the substantial rights of the petitioner may have been prejudiced because the administrative findings, inferences, conclusions, or decisions are unsupported by substantial evidence.Minn. Stat. ß 14.69.The party seeking review of the agency decision has the burden of proof under section 14.69.See Markwardt v. State, Water Resources Bd., 254 N.W.2d 371, 374 (Minn. 1977) (discussing Minn. Stat. ß 15.0425 governing review of administrative agency actions, the predecessor to Minn. Stat. ß 14.69).In this case, respondent carries the burden of proving that the commissionerís decision in not supported by substantial evidence.

Appellant argues that the district court erred in overturning the decision of the commissioner because the commissionerís decision was supported by substantial evidence.Appellant asserts that respondent, as the party with the burden of proof, is unable to show that substantial evidence does not support the commissionerís decision.[3]Substantial evidence is defined in part as ďsuch relevant evidence as a reasonable mind might accept as adequate to support a conclusion.ĒCable Communications Bd. v. Nor-West Cable Communications Partnership, 356 N.W.2d 658, 668 (Minn. 1984).

Appellant does not dispute the diagnosis of DID nor dispute that Dr. Ostromís treatment plan is within the International Society for the Study of Dissociation (ISSD) guidelines.Appellant disputes only whether respondent has fulfilled the requirements necessary for prior authorization of the DID treatment plan.Prior authorization for medical-assistance program health services is approved only if, in addition to other criteria, the proposed service is: (1) medically necessary as determined by prevailing medical community standards or customary practice and usage, and (2) the most cost effective health care option available.Minn. R. 9505.5030.A, E(1998); see also Minn. R. 9505.0175, subp. 25 (1998).

I.

The commissioner determined that the ISSD guidelines are not the prevailing community standard for treating DID and therefore concluded that BHSI was justified in denying Dr. Ostromís request for treatment based on ISSD standards.[4]Although we give great deference to agency expertise, the commissionerís decision in this case is not supported by substantial evidence.See Reserve Mining Co. v. Herbst, 256 N.W.2d 808, 824 (Minn. 1977) (holding that agency decisions enjoy a presumption of correctness).We recognize that we must determine whether substantial evidence supports the commissionerís decision, and not whether substantial evidence supports another conclusion.See Minn. Stat. ß 14.69(e).But here there can be only one prevailing community standard and substantial evidence does not support the commissionerís decision that the ISSD guidelines are not the prevailing community standard.On the contrary, the evidence supports a determination that the ISSD guidelines are the prevailing community standard for the treatment of DID.

The ISSD has more than 2000 members, and is the only mental health organization, identified by any party to this dispute, committed to the goal of expanding knowledge of DID.The ISSD guidelines are one of only two published guidelines outlining the treatment for DID in the United States.

Despite this evidence appellant continues to assert that the ISSD guidelines are not the prevailing community standard because: (1) the guidelines are based on anecdotal and uncontrolled clinical reports; and (2) the guidelines themselves state that treatments may differ in significant ways from those suggested in the guidelines.However, the ISSD guidelines offer an explanation for appellantís observations. The authors explain that the guidelines are based on anecdotal reports because few therapists treated DID before the 1980ís; therefore, there are a limited number of published cases to use as a basis for establishing guidelines.The guidelines recognize that all medical treatment is individualized, but they offer a summary of the most common beneficial treatment of treating DID patients.In addition, appellantís expert is not a DID specialist and admits that BHSI has not developed a specific DID treatment approach.†† BHSIís pre-authorization of DID treatment is not based on specific standards for DID, but rather the authorization is based on the general needs of those patients who have severe and chronic long-standing problems with instability.

The substantial evidence here supports a finding that the ISSD guidelines are the presently prevailing community standard for treatment of DID.[5]

II.

The commissioner also questioned whether Dr. Ostromís treatment was the most cost effective health service available for respondentís needs. The commissioner concluded that Dr. Ostrom did not bring forward ďempirical evidence to demonstrate that a less intensive level of service would fail to meet her [respondentís] needs as opposed to her preferences.ĒThe Minnesota rules defining medical necessity do not require respondent to show empirical evidence of the most cost effective health service.Minn. R. 9505.5030.A, E (1998).Dr. Ostrom has repeatedly detailed in his treatment requests that integration of respondentís alternative personalities is necessary because of respondentís suicidal tendencies.In light of the ISSD guidelines suggesting twice-weekly two-hour therapy sessions and respondentís suicidal tendencies, Dr. Ostromís request for one and one-half hour sessions once per week is reasonable and the most cost effective plan for treating respondentís DID.

Affirmed.

 



[1]Behavioral Health Services Inc. (BHSI) is a wholly owned subsidiary of Blue Cross/Blue Shield of Minnesota.The Minnesota Department of Human Services (DHS) has contracted withBlue Cross/Blue Shield to provide health care services to enrollees in its publicly funded health care program, MinnesotaCare. BHSI is responsible for authorizing all mental health services requested on behalf of MinnesotaCare enrollees.Respondent is a MinnesotaCare enrollee.

[2] The hearing referee declined to consider BHSIís decision concerning the 1997 treatment program because at the time of the hearing, August 1998, respondent had finished her 1997 treatment.The district courtís order does not address the 1997 treatment program and respondent does not request that this court review BHSIís denial of Dr. Ostromís 1997 treatment request and therefore this appeal is limited to the 1998 treatment request.

[3]Respondent focuses her argument on the substantial evidence that supports her position that the ISSD guidelines are the prevailing community standard for treating DID.Appellant would like to characterize respondentís approach to this legal issue as a mischaracterization of the standard of review.Although, this court reviews the evidence presented at the appeals hearing to determine if substantial evidence supports the commissionerís decision, respondentís argument is not inconsistent with this standard.Respondent argues that the ISSD guidelines are the prevailing community standard for treatment, and therefore any other treatment, including the treatment approved by the DHS, cannot be the prevailing community standard for treatment.

[4] The DHS adopted the ISSD guidelines as the prevailing community standard in a DID treatment request case following this case in October 1998.

[5] Although we find the ISSD guidelines are the prevailing community standard in the treatment of DID, under the facts of this case, in part because appellant does not present any other satisfactory alternatives, we do not minimize appellantís concerns with these anecdotal and amorphous guidelines.Indeed, according to a recent study published in the American Journal of Psychiatry, there is little consensus among board-certifiedamerican psychiatrists regarding the diagnosis, or existence of, Disassociate Identity Disorder (DID).Harrison G. Pope Jr. et al., Attitudes Toward DSM-IV Dissociative Disorders Diagnoses Among Board-Certified American Psychiatrists, 156 Am.J. Psychiatry 321 (1999).