An anticipated decision by the 11th Circuit Court of Appeals may alter the way medical treatment is dispensed for Medicaid recipients.  Under the current system, Medicaid recipients are entitled to receive 'medically necessary' treatment as prescribed by their physician.  In cases of disabled or handicapped people this frequently means home nursing care by a CNA or therapist. 

The case pending before the 11th Circuit involves Anna Moore, a 14-year-old Georgia girl, who suffers from a seizure disorder since birth.  Because of her ongoing risk of stroke and breathing problems, Anna's physician prescribed round-the-clock nursing care. Despite the medical order from Anna's physician (and years of approving the nursing services), officials at Georgia Medicaid decided to arbitrarily reduce the number of weekly hours provided by a home nurse. The reduction occurred despite the fact there was no change in Anna's medical condition.

Anna’s mother initiated a lawsuit against Georgia Medicaid to force the government agency to provide home nursing as prescribed by Anna’s physician.  The decision is now in the hands of the Appellate court after a lower court ruled in favor of the disabled girl.

At issue is the state’s right to overrule medical orders from a treating physician because the state does not agree with the prescribed treatment.  Advocates for Medicaid recipients question the financial motive behind an administrative agencies right to withhold medical treatment.  “[I]f a state budget is pinched, what might have been medically necessary in June won’t be in July…and a medical opinion as to the necessity as to necessity simply isn’t relevant,” said Greg Mellowe a healthcare policy directory at Florida CHAIN.

Lawyers for the state question the medical necessity of some of the treatments prescribed by physicians.  “When left to their own devices, they advocate for their patients and deem all manner of unproved, dangerous, ineffective, cosmetic, unnecessary, bizarre, and controversial treatments as ‘medically necessary,’” according to a court brief filed by the Florida Attorney General.

The 11th Circuit’s decision directly impacts the states in its jurisdiction: Florida, Georgia and Alabama, but the courts ruling will likely set a precedent for all Medicaid recipients in other states.  The court’s ruling will likely be issued in several months.

Read more about this pending court decision here.