In re Gwin

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

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 (AHCCCS) — the state’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, claiming that HIV was a contraindication for a transplant — a treatment it considered “experimental.” 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 and the Arizona Center for Disability Law advocated with AHCCCS, resulting in the agency modifying its policies governing the 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, people with HIV 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, the state’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 revised its policies regarding the eligibility of people with HIV for transplants. This is one of many Lambda Legal cases that have ensured that people with HIV receive fair and equal access to medical care and other critical services.