Opinion ID: 214263
Heading Depth: 3
Heading Rank: 4

Heading: Pittman ex rel. Pope v. Secretary, Florida Department of Health & Rehabilitative Services

Text: Next came Pittman ex rel. Pope v. Secretary, Florida Department of Health & Rehabilitative Services , which construed the 1989 Amendment and its effect on a state Medicaid agency's EPSDT obligations. The plaintiff in Pittman, a Medicaid-eligible child, sought a preliminary injunction requiring the state of Florida to pay for a liver-bowel transplant. 998 F.2d at 887. The plaintiff's doctors believed this transplant could save his life; otherwise, he was likely to die of liver failure within a year. Id. at 888. [57] The Florida Department of Health and Rehabilitative Services denied the plaintiff's request for a transplant at the administrative level, contending that the liver-bowel transplant was experimental and, accordingly, Florida was not obligated to provide Medicaid funding. Id. Once in the district court, Florida did not defend its denial of Medicaid funding on the ground that the transplant was experimental. Id. Florida instead staked its position on a provision of the Medicaid Act, 42 U.S.C. § 1396b(i)(1), [58] which it claimed vested states with discretion to deny coverage for organ transplants in the state's Medicaid plan. Id. The plaintiff, meanwhile, argued that § 1396d(r)(5) of the Medicaid Act entitled him to coverage for all medically necessary care, regardless of whether a state plan allowed for it. Id. at 889. This Court agreed with the plaintiff, concluding that Florida lacked discretion to withhold funding for medically necessary organ transplants with respect to Medicaid recipients under the age of 21. Id. at 891-92. In so doing, we acknowledged a circuit split regarding whether § 1396b(i)(1) provides an affirmative grant of discretion to states to deny coverage for organ transplants, or whether § 1396b(i)(1) merely delineates conditions for federal funding of organ transplants. Id. at 890-91. The Pittman Court agreed with the reasoning of the Fourth Circuit, which previously addressed the issue in Pereira ex rel. Pereira v. Kozlowski, 996 F.2d 723 (4th Cir.1993). Pittman, 998 F.2d at 891. The Pittman Court found persuasive the Fourth Circuit's conclusions in Pereira that (1) § 1396b(i)(1) merely imposed conditions on federal funding of organ transplants, rather than endowing participating states with discretion to exclude organ transplants from their plans and (2) the legislative history did not suggest otherwise. Id. The Pittman Court ultimately determined it was unnecessary to decide whether § 1396b(i)(1) grants any such discretion, given the clear language of § 1396d(r)(5). Id. The Pittman Court concluded that, even if § 1396b(i)(1) vested the states with authority to withhold organ transplant funding, § 1396d(r)(5) subsequently took this discretion away with respect to Medicaid-eligible individuals under the age of 21. Id. at 892. We therefore reversed the district court's denial of a preliminary injunction in plaintiff's favor against Florida. Id. Ultimately, Pittman does not help answer the question presented here. DCH does not dispute that private duty nursing services are medically necessary for Moore and required under the Medicaid Act DCH only disputes the amount of services that are medically necessary. Unlike the hours of nursing care involved here, the organ transplant in Pittman was an all-or-nothing transaction. More importantly, Florida did not argue that the plaintiff's liver-bowel transplant was not medically necessary. Rather, Florida placed all its eggs in the § 1396b(i)(1) basket, arguing it had discretion to exclude transplants under its state plan. Once the Pittman Court rejected this argument, therefore, it did not need to address whether the liver-bowel transplant was medically necessarylet alone the respective roles of state Medicaid agencies and treating physicians in making such determinations thus demonstrating Pittman 's limited applicability to this case. See id. at 888 n. 3. [59]