AI Generated Opinion Summaries

This summary was computer-generated without any editorial revision. It is not official, has not been checked for accuracy, and is NOT citable.

Facts

• After suffering a severely disabling anoxic brain injury, Albert Rodarte sought pre-approval from Presbyterian Insurance Company for his daughter, Jessica, to receive hyperbaric oxygen therapy (HBOT). Presbyterian denied the request, concluding the treatment was not a covered benefit and not "medically necessary" under the New Mexico Administrative Code. The New Mexico Superintendent of Insurance upheld this denial, agreeing with Presbyterian's assessment. The district court, however, reversed the Superintendent's decision, finding HBOT to be a covered benefit and medically necessary (paras 1-9).

Procedural History

• District Court of Santa Fe County: Reversed the Superintendent's decision, finding HBOT to be a covered benefit and medically necessary.
• Court of Appeals of New Mexico: Accepted certiorari to review the district court's ruling and reversed the district court's decision, upholding Presbyterian's denial of coverage for HBOT (paras 2, 32).

Parties' Submissions

• Appellant-Respondent (Rodarte): Argued that HBOT should be considered a covered benefit under Jessica's health plan and that it was medically necessary for her condition.
• Appellee-Petitioner (Presbyterian Insurance Company): Contended that HBOT was not a covered benefit under the health plan and that it was not medically necessary for Jessica's condition according to the plan and the New Mexico Administrative Code.
• Appellee (New Mexico Superintendent of Insurance): Upheld Presbyterian's denial of coverage, agreeing that HBOT was not a covered benefit and not medically necessary under the plan and the Code (paras 3-9).

Legal Issues

• Whether HBOT treatments are a covered benefit under Presbyterian’s plan for Jessica’s medical condition.
• Whether such treatments are medically necessary under regulations adopted by the Superintendent requiring a plan to provide medically necessary services.
• Whether the district court was correct to reverse the Superintendent (para 11).

Disposition

• The Court of Appeals of New Mexico reversed the judgment of the district court and reinstated the final order of the Superintendent upholding Presbyterian’s denial of coverage for HBOT (para 32).

Reasons

• The Court of Appeals found that the Presbyterian insurance contract unambiguously restricted coverage for HBOT to a series of named conditions and excluded coverage of HBOT for all other treatments, including Jessica’s condition. It also held that HBOT was not medically necessary to treat Jessica’s medical condition under the New Mexico Administrative Code. The Court determined that the district court improperly concluded that HBOT was a covered benefit and improperly applied the definition of "medical necessity" under the Code. The Court's review of the administrative record supported the Superintendent's determination that HBOT did not meet the requirements necessary to establish medical necessity for Jessica's condition (paras 12-31).