## Facts

- Elizabeth M. Russell, a Medicare beneficiary, developed a large, non-healing abdominal wound after hernia surgery and experienced fatigue, nausea, and pain.
- From June through December 2004, she received daily skilled nursing care at home for wound treatment and monitoring.
- She sought Medicare Part A coverage for home-health services; the agency denied the claim on the ground that she was not “homebound.”
- Russell and her sister submitted affidavits stating Russell generally stayed home; her sister visited multiple times daily to assist with household needs and dog care.
- The affidavits described Russell leaving home only for short, assisted dog walks (about 50 feet) and occasional grocery trips in which her sister did the driving, lifting, and carrying; Russell returned home exhausted and needing rest.
- The administrative record contained nursing notes that were mixed, with some suggesting she could leave home independently and others describing her as effectively homebound.
- The ALJ relied on evidence that Russell could leave home for nonmedical activities (including shopping) and could ambulate without assistive devices, concluding leaving home did not require a “considerable and taxing effort.”
- The Medicare Appeals Council adopted the ALJ’s decision as the final decision of the Secretary, and Russell sought judicial review under 42 U.S.C. §§ 405(g) and 1395ff(b)(1).

## Issues

1. Whether the ALJ applied the correct statutory and regulatory standard for Medicare’s “homebound” requirement for home-health coverage.
2. Whether the finding that Russell was not homebound was supported by substantial evidence in the administrative record.

## Decision

- The district court reversed the Secretary’s final decision and remanded for further proceedings.
- The court granted Russell’s motion to reverse and denied the Secretary’s motion to affirm.
- The court adopted the magistrate judge’s recommendation that the denial rested on an improper application of the “homebound” standard and was not supported by substantial evidence.

## Legal Principles

- Medicare home-health coverage requires, among other conditions, that the beneficiary be “confined to the home,” meaning a normal inability to leave home and that leaving home requires a considerable and taxing effort.
- A beneficiary need not be bedridden to satisfy the homebound requirement.
- Occasional, brief absences from the home for nonmedical purposes do not automatically defeat homebound status if the regulatory criteria are otherwise met.
- On review under 42 U.S.C. § 405(g), a court must set aside an agency decision that applies an incorrect legal standard or that is not supported by substantial evidence when the record is considered as a whole.
- An ALJ may not treat isolated instances of leaving home, or the absence of an assistive device, as dispositive where other record evidence indicates departures are exceptional, assisted, and physically taxing.

## Conclusion

The court held that the agency’s denial of Medicare home-health coverage rested on an overly restrictive view of “homebound” status and did not fairly account for evidence that Russell’s limited, assisted outings were consistent with a normal inability to leave home and the need for considerable and taxing effort; the matter was therefore reversed and remanded for further administrative proceedings.


Russell v. Sebelius, 686 F. Supp. 2d 386 (D. Vt. 2010)