Moore Ex Rel. Moore v. Reese
2011 U.S. App. LEXIS 7126
| 11th Cir. | 2011Background
- Moore is a 16-year-old Medicaid recipient with multiple severe disabilities requiring continuous skilled nursing care at home.
- Georgia’s DCH reduced Moore’s private duty nursing hours from 94 to 84 per week, citing medical necessity and caregiver considerations.
- GMCF Medical Review Team (under contract with DCH) reviews medical records and approves nursing hours based on medical necessity and caregiver training needs.
- Moore’s treating physician (Dr. Braucher) repeatedly recommended 94 hours per week, reflecting Moore’s complex needs and history of hospitalizations and interventions.
- GAPP is Georgia’s home-based private duty nursing program; its Manual contemplates joint determination of medical necessity by treating physicians and GMCF, with time-limited approvals and reauthorization every three months.
- The district court granted Moore partial summary judgment, concluding the treating physician’s opinion controlled; on appeal, the Eleventh Circuit reversed and remanded, holding that both the physician and the state may play roles in determining medical necessity and that material factual disputes remained.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the state may review and limit medical-necessity amounts despite treating-physician recommendations. | Moore argues treating-physician’s 94 hours must be honored. | DCH may place limits based on medical necessity under 42 C.F.R. § 440.230(d). | State may review and limit; physician’s view is not dispositive. |
| Whether 84 hours is sufficient to meet Moore’s medical needs; who bears burden at trial. | Moore contends 94 hours are medically necessary. | 84 hours may be medically necessary given stability and caregiver capacity. | Material facts about sufficiency of 84 vs. 94 hours preexist for trial. |
| Whether EPSDT requires Moore to receive all medically necessary private duty nursing hours. | EPSDT mandates all medically necessary care regardless of cost. | EPSDT allows reasonable limits on services for medical necessity and utilization control. | EPSDT obligates medically necessary care but allows state-imposed limits on amount, duration, and scope. |
| Whether the CMS Manual and Georgia’s GAPP framework support dual-role review by state and physician. | Beal/Rush require treating physician’s role; state should defer to physician. | CMS Manual and Rush permit state to define medical necessity and review case-by-case. | Dual-role framework is valid; state may present its own medical-necessity evidence consistent with regulations. |
Key Cases Cited
- Beal v. Doe, 432 U.S. 438 (1977) (state broad discretion to set medical-necessity standards; not required to fund all requested services)
- Curtis v. Taylor, 625 F.2d 645 (5th Cir. 1980) (states may limit physician services so long as limits are reasonable and not discriminatory)
- Rush v. Parham, 625 F.2d 1150 (5th Cir. 1980) (state may define medical-necessity and review physician’s determinations case-by-case; physician not sole arbiter)
- Pittman ex rel. Pope v. Secretary, Florida Dept. of Health & Rehab. Services, 998 F.2d 887 (11th Cir. 1993) (EPSDT under 1396d(r)(5) requires medically necessary care for children; state may not deny all such care purely by statute)
- Pereira ex rel. Pereira v. Kozlowski, 996 F.2d 723 (4th Cir. 1993) (courts address scope of medical-necessity in EPSDT context)
- Hood v. Hood, 391 F.3d 581 (5th Cir. 2004) (CMS interpretation of EPSDT and state regulation limits within medical-necessity framework)