I.b. ex rel. R.B. v. State, Agency for Health Care Administration, 2012 Fla. App. LEXIS 3162

I.B. is a five-year-old with autism who is non-verbal and needs ADL assistance, including meal prep, feeding, dressing, hygiene, and incontinence care.
I.B. lives with his mother and sister, attends school, and receives Medicaid-funded services including speech and occupational therapy.
AHCA contracted KePRO to review and authorize I.B.’s Medicaid home health PCA hours, which initially recommended reduced hours.
A second KePRO physician further reduced PCA hours, excluding care during therapy and affecting family transportation needs, leading to a Fair Hearing request.
A hearing officer attributed medical necessity to a misapplied rule set and relied on testimony deemed erroneous, ultimately upholding the reduced PCA hours.
The court reversed and remanded, holding the hearing officer used an incorrect standard and that EPSDT requirements and competent evidence support more PCA hours.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Was medical necessity determined under the correct standard?	I.B. should be evaluated under PCA standard in the Home Health Handbook.	AHCA applied Florida Administrative Code 59G-1.010 and 59G-4.290.	Yes; incorrect standard applied, reversal warranted.
Did the hearing officer rely on proper evidence to support hours?	Evidence was competent; EPSDT mandates require coverage for minors.	Testimony supported the reduced hours under the applicable rules.	No; evidence was flawed and not competent; remand necessary.
Did EPSDT require transportation-related PCA hours for I.B.?	EPSDT mandates require necessary health care, including transport to therapies at no cost where needed.	State policy did not cover transportation under the cited rules.	Yes; EPSDT requires coverage of necessary health services, including transportation.

C.F. v. Dep’t of Children & Families, 934 So.2d 1 (Fla. 3d DCA 2005) (EPSDT mandates; error of law when applying restrictive medical-necessity standards)
Jacoby v. Bd. of Med., 917 So.2d 358 (Fla. 3d DCA 2005) (findings reviewed for competent substantial evidence; interpretations de novo)