Detgen Ex Rel. Detgen v. Janek
2014 U.S. App. LEXIS 9107
| 5th Cir. | 2014Background
- Four Medicaid beneficiaries with near-total physical disabilities sought ceiling lifts (DME) to assist mobility at home.
- Texas HHSC denied coverage under a categorical exclusion in its Medicaid regulations.
- The district court granted summary judgment, holding no obligation to provide lifts if federal funds were not available.
- CMS later issued guidance stating federal participation would be available for these items.
- Plaintiffs pursued appellate review arguing Supremacy Clause implied private action and preemption issues; Texas argued no private action and no preemption.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Do plaintiffs have an implied private action to enforce Medicaid under the Supremacy Clause? | PPHST supports implied action to enforce Spending Clause laws. | Supremacy Clause does not create a private remedy; only government enforcement via funds. | Yes; implied private action exists under PPHST. |
| Can state violations of the Medicaid Act be enjoined or privately enforced? | State violates federal requirements via exclusions; private action allowed. | A state may risk funds but cannot be sued for violation. | Private action is possible; state violations may be challenged. |
| Are categorical exclusions of ceiling lifts reasonable under 1396a(a)(17) and 440.230(b)? | Ceiling lifts are medically necessary; exclusion is unreasonable. | States have broad discretion; exclusions can be reasonable with cost-effective alternatives. | Exclusion deemed reasonable; no violation found. |
| Does CMS guidance or prior cases require denial of categorical exclusions? | DeSario letter and CMS guidance discourage blanket exclusions. | Guidance does not prohibit reasonable categorical exclusions; DeSario not controlling. | Guidance does not render exclusion unlawful; allowed. |
Key Cases Cited
- Planned Parenthood of Houston & Southeast Texas v. Sanchez, 403 F.3d 324 (5th Cir. 2005) (Supremacy Clause implies private action to enforce Spending Clause laws)
- Harris v. McRae, 448 U.S. 297 (Supreme Court) (participation in Medicaid optional but once accepted must comply with Title XIX)
- Hope Medical Group for Women v. Edwards, 63 F.3d 418 (5th Cir. 1995) (distinguishes cases where benefit is generally available vs. categorically excluded)
- Rush v. Parham, 625 F.2d 1150 (5th Cir. 1980) (cannot deny treatment solely by diagnosis or condition)
- S.D. ex rel. Dickson v. Hood, 391 F.3d 581 (5th Cir. 2004) (limits of children’s benefits do not mandate adult equivalents)