11th Circuit Decision Allows State to Trump Physicians’ Order For Medicaid Care for Children

On April 24, 2009, the 11th Circuit Court of Appeals reversed a district court holding that suggested the state’s Medicaid agency would have to provide for the amount of skilled nursing care that child’s treating physician had ordered. In rendering its decision, the panel interpreted a federal law that requires states participating in the Medicaid program to provide any screening, diagnostic and treatment services necessary to “correct or ameliorate” the medical conditions of Medicaid-eligible children. The three-judge panel concluded that the state and the treating physician must share the role of determining what services that may be medically necessary or proper for a child’s medical condition, noting that the “physician’s word on medical necessity is not dispositive.”

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