Opinion ID: 3049029
Heading Depth: 5
Heading Rank: 1

Heading: Physicians’ role

Text: The committee’s bill provides that the physician is to be the key figure in determining utilization of health services and provides that it is a physician who is to decide upon admission to a hospital, order tests, drugs and treatments, and determine the length of stay. For this reason the bill would require that payment could be made only if a physician certifies to the medical necessity of the services furnished. Pinneke, 623 F.2d at 549 n.3 (quoting Senate Report). 56 We can reconcile Rush with Curtis because both indicate that the state not only has a role to play as to medical necessity but also is not required to accept the treating physician’s opinion of medical necessity. Any differences in Rush and Curtis stem from the markedly disparate factual contexts in which the cases arose. Georgia’s limitation in Rush was a blanket denial of a particular type of medical service, sex reassignment surgery. In contrast, Florida’s limitation in Curtis—funding only three doctor visits a month, excluding emergencies—was quantitative in nature. See pp. 86-88, infra. In any event, to the extent any portion of Rush arguably conflicts with the holding in Curtis, we are bound by Curtis, which preceded Rush. See United States v. Smith, 122 F.3d 1355, 1359 (11th Cir. 1997) (per curiam) (“Under the prior panel precedent rule, we are bound by earlier panel holdings . . . unless and until they are overruled en banc or by the Supreme Court.”). 66 definition of medical necessity that places reasonable limits on a physician’s discretion,” id. at 1154; and (3) “a state Medicaid agency can review the medical necessity of treatment prescribed by a doctor on a case-by-case basis,” id. at 1155. At a minimum, this complicated postulation of multiple levels of scenarios on remand is dicta and does not undermine Rush’s earlier clear holdings. A decision can extend no further than the facts and circumstances of the case in which it arises. See, e.g., Watts v. BellSouth Telecomms., Inc., 316 F.3d 1203, 1207 (11th Cir. 2003) (“Whatever their opinions say, judicial decisions cannot make law beyond the facts of the cases in which those decisions are announced.”); United States v. Aguillard, 217 F.3d 1319, 1321 (11th Cir. 2000) (per curiam); United States v. Eggersdorf, 126 F.3d 1318, 1322 n.4 (11th Cir. 1997). Alternatively, however we classify this last paragraph, the Rush Court’s suggestions about “utilization review” appear to apply only in limited circumstances. To fully understand and place in context this “utilization review” paragraph of Rush, it is helpful first to examine what the district court did in Rush by comparison. The district court in Rush had opined that the state must pay for any medical services prescribed by the treating physician and that the state’s review of a treating physician’s recommendation was, in all circumstances, limited to a utilization review, id. at 1154 n.6—a conclusion which, on appeal, the Rush 67 Court explicitly rejected, id. at 1154-55. In the last paragraph of Part B, the Rush Court conjectured that the state is restricted to a utilization review only if (1) under Georgia’s plan, experimental treatment was not limited to exceptional cases but provided more generally, or (2) if the district court made a threshold finding that Georgia was unreasonable in determining that sex reassignment surgery was experimental. In other words, the district court in Rush erred in concluding that the state’s reviewing authority is limited to a “utilization review” in all circumstances. Rather, the Rush Court’s musings in the last paragraph of Part B suggest that the state is limited to a utilization review in circumstances where the state has placed no limitation at all on experimental treatment or where the state’s attempt to place a medical necessity limitation on a service was deemed contrary to “current medical opinion,” id. at 1157 n.13, and thus unreasonable.