Followup on interpreting Medicaid regs

The 11th Circuit has handed down its opinion in the case of Moore v. Medows, described in our March 25th post, "Interpreting Medicaid regs". See "Law.com - 11th Circuit: Doctors Don't Trump State on Medicaid Care for Children With Disabilities":

A federal appeals panel has declared that treating doctors don't have the final say in how much nursing care the state must provide children with disabilities under Medicaid.

Friday's ruling by the 11th U.S. Circuit Court of Appeals reversed a district judge's decision that had said the state must provide the amount of nursing care that a North Georgia girl's doctor said she needs.

Despite a slew of amicus briefs by state governments and Medicaid plan administrators, the panel dispatched the case in a two-page, unpublished, unsigned opinion that came out a month after oral argument. ...

In 2006, the state informed Callie's mother that it was reducing Callie's nursing hours from 94 hours a week to 84, contrary to the recommendation of Callie's primary care physician. Callie's mother filed suit.

The Moores' lawyers convinced Thrash that the reduction was improper. After issuing multiple injunctions in Callie's favor, he denied the state's motion for summary judgment and granted the Moores' motion in part, concluding the state must provide for the amount of skilled nursing care that Callie's treating physician deems necessary. ...

The panel said both the state and Callie's physician have roles in determining what's medically necessary to correct or ameliorate Callie's medical conditions. It cited a federal regulation that says a Medicaid agency "may place appropriate limits on a service based on such criteria as medical necessity or utilization control procedures."

"A private physician's word on medical necessity is not dispositive," the panel concluded. ...

The state has limited discretion to deny a provider's request for care under the "early and periodic screening, diagnostic and treatment services" portion of the Medicaid Act, said Thrash. He added that "[t]he state's discretion is limited to a review of the request for fraud, abuse of the Medicaid system, and whether the service is within the reasonable standards of medical care."

EMM