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Doe v. Managed Care Organization



In the first legal ruling of its kind in the country, GLAD prevailed in an action to cover the cost of a life-saving liver transplant for a Medicaid recipient with both HIV and end-stage liver disease as a result of hepatitis C. The case was brought on behalf of a 41 year-old Roxbury, MA man who was in no danger of dying from his HIV, but would have died within months of Hepatitis-related liver disease without the transplant. Medicaid coverage was denied on the ground that liver transplants are “experimental” – and, therefore, are not covered – in the presence of HIV infection. On appeal, the Division of Medical Assistance Board of Hearings rejected the claim that liver transplantation is “experimental” in people with HIV. As a result of this decision, insurers cannot categorically exclude people with HIV from liver transplantation.