Court says states can decide medical necessity under Medicaid

A new decision by a federal appeals court has concluded that physicians don't have sole discretion in determining what's medically necessary treatment for children with Medicaid coverage. The decision, by the 11th U.S. Circuit Court of Appeals, held that the state also has the right to weigh in on what's needed.

The court's ruling came from a case in which the physician for 12-year-old Anna C. Moore prescribed 94 hours of private skilled nursing per week. However, the state of Georgia's Department of Community Health approved only 84 hours for Moore, who has severe disabilities after having an in-utero stroke.

Moore's family sued the DCH, arguing that it violated a provision of the Medicaid act requiring that states cover services needed to "correct or ameliorate" a child's condition. The family won in federal trial court, with the trial court deciding that the state didn't have the authority for the denial, but the state appealed.

To learn more about this case:
- read this American Medical News piece

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