Justia U.S. 11th Circuit Court of Appeals Opinion Summaries

Plaintiff, a 16-year-old Medicaid recipient who was severely disabled, sued Defendant for allegedly violating the Medicaid Act ("Act") by reducing plaintiff's Medicaid-funded private duty nursing care from 94 to 84 hours per week. At issue was whether summary judgment in favor of plaintiff was proper where defendant's application of the Georgia Pediatric Program plan to plaintiff's specific medical condition violated the Act when 94 nursing hours at home was in fact medically necessary given plaintiff's condition and when the district court restricted defendant's role in reviewing plaintiff's treating physician's determination of nursing hours only for fraud or abuse of the Medicaid system and for whether the services was within the reasonable standards of medical care. The court held that the district court erred in granting summary judgment in favor of plaintiff and too narrowly limited defendant's role in reviewing plaintiff's treating physician's determination of nursing home hours where the record presented issues of material fact over what amount of private duty nursing hours were medically necessary for plaintiff and where a state may still review the medical necessity of the amount of nursing care prescribed by the treating physician and make its own determination of medical necessity.