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Medicaid Can Limit Services to Special Needs Children According to 11th Circuit Court of Appeals Decision

By Stephanie F. Brown, Attorney and David Wolf, Attorney
Published by Child Injury Lawyer Network


In an 11th Circuit Federal Court of Appeals decision, the court reversed a federal district court opinion that held the State Medicaid program must provide the level of nursing services deemed necessary by a disabled child’s doctor. This case involved a North Georgia teenager who suffers from mental retardation and cerebral palsy. Her doctor ordered 24 hour in home nursing care.

While the district court found that this amount of in home nursing care was an abuse of the Medicaid system, the district court nonetheless held that the State’s policy of refusing to provide in home nursing care for 16 to 24 hours per day for more than a week was also inappropriate. The district court held that this refusal by the State was no based on what is medically necessary for the patient.

On appeal, however, the 11th Circuit reversed the district court and held that both the State and the private physician have roles in determining what is medically necessary for the patient. In so holding the Court relied on a federal regulation that permits states to place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures. The Court has remanded the case to the District Court for further proceedings. Essentially, the 11th Circuit, although reversing, has passed the buck back to the District Court to further address the role of the State and the doctor in determining what care is medically necessary for this disabled child.

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