Source: https://healthlaw.org/resource/q-a-on-epsdt-moore-v-reese-11th-circuit-case/
Timestamp: 2019-04-22 08:35:49+00:00

Document:
This factsheet discusses Moore v. Reese, an 11th Circuit case concerning proper amount of covered service.
Q. My client has an 11-year-old daughter whose doctor requested coverage for 80 hours per week of private duty nursing. The state Medicaid agency denied the request, stating that 80 hours were unnecessary and authorizing 30 hours per week. The state?s attorney cited Moore v. Reese. Please explain this case and how it could affect my clients who depend on EPSDT.
A. Moore v. Reese is a recent case decided by the Eleventh Circuit Court of Appeals. The case requires the impartial decision-maker (administrative or judicial) to weigh both the treating provider and the state?s arguments when there is a disagreement as to the proper amount of a covered Medicaid service.
Moore v. Reese was filed after the Georgia Medicaid agency reduced coverage of Callie Moore?s private duty nursing services from 94 to 84 hours per week over the objection of Callie?s long-time treating physician. See Moore v. Reese, 637 F.3d 1220, 1224-29 (11th Cir. 2011) (petition for rehearing denied, May 15, 2011).
[t]he state must provide for the amount of skilled nursing care which the Plaintiff’s treating physician deems necessary to correct or ameliorate her condition. The Defendant may not deny or reduce the hours of skilled nursing care that is medically necessary based upon cost or the lack of a secondary caregiver.
Moore v. Medows, 563 F. Supp. 2d 1354, 1357 (N.D. Ga. 2008). The district court relied on 1989 amendments to the Medicaid Act?s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provisions, which require states to cover necessary services listed in the Medicaid Act (§ 1396d(a)) when needed to ?correct or ameliorate? a child?s physician or mental condition. Id. (citing 42 U.S.C. § 1396d(r)(5)). The court concluded that these amendments strictly limited the state?s discretion not to provide physician-prescribed treatments for individuals under age 21. Id.
Georgia is required to adhere to the Medicaid EPSDT provisions and must cover private duty nursing services under EPSDT when they are medically necessary to correct or ameliorate a child?s condition.
The state?s Medicaid plan must include reasonable standards for determining the extent of medical assistance that must be consistent with Medicaid?s objectives, specifically EPSDT.
The state can adopt a definition of medical necessity that places limits on a service based on medical necessity, therefore limiting a physician?s discretion so long as the state does not discriminate based on condition. The state can also establish standards for a physician to use when determining what services are necessary in a particular case.
The state can establish the amount, duration and scope of services required under EPSDT (citing 42 C.F.R. § 440.230 and the State Medicaid Manual) and is not required to provide medically unnecessary, though desired, EPSDT services.
The treating physician assumes the primary responsibility for determining the child?s treatment needs, but both the state and physician have roles to play. If there is a dispute over the proper amount of a service that Medicaid will cover, the decision-maker should review the recommendation of the treating physician on a case-by-case basis and allow the state agency to present its own evidence of medical necessity.

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