In S.D. v. Hood, 391 F.3d 581, (5th Cir. 2004), S.D., a sixteen year old with total bowel and bladder incontinence as a result of spina bifida, sued because the Louisiana Medicaid agency refused to cover incontinence underwear. The underwear had been prescribed by a physician as health care necessary to correct or ameliorate S.D.s mental and physical conditions. The physician noted that the underwear would prevent chronic irritation and infection that would otherwise result from urine wetness. Also, without it, S.D. would be unable to leave his home, isolated and unable to attend school or other activities, thus harming his mental health.
The Medicaid agency denied coverage, claiming that the disposable underwear was not medically necessary and was a non-medical supply not covered by the Medicaid program. At a fair hearing, an ALJ upheld the denial. S.D. successfully appealed to the federal district court, which held that the EPSDT laws are enforceable and that S.D. was entitled to Medicaid coverage for the incontinence supplies. See 2002 US Dist. LEXIS 23535 (E.D. La. Dec. 5, 2002). On appeal, the Fifth Circuit unanimously affirmed the District Court, holding that Louisiana is required to provide all Medicaid covered services to beneficiaries under 21 when they are necessary to correct or ameliorate a condition. The Court stated that
[t]he plain words of the state and the legislative history make evident that Congress intended that the health care, services, treatment and other measures that must be provided under the EPSDT program be determined by reference to federal law, not state preferences.
391 F.3d at 592.
It also ruled that the disposable incontinence underwear needed by S.D. is a covered Medicaid service under the category of home health services which includes supplies, equipment and appliances suitable use in the home. Id. at 595. Finally, the court rejected the states argument that Medicaid beneficiaries could not enforce the EPSDT requirements in court.
In S.D. v. Hood, 391 F.3d 581, (5th Cir. 2004), S.D., a sixteen year old with total bowel and bladder incontinence as a result of spina bifida, sued because the Louisiana Medicaid agency refused to cover incontinence underwear. The underwear had been prescribed by a physician as health care necessary to correct or ameliorate S.D.s mental and physical conditions. The physician noted that the underwear would prevent chronic irritation and infection that would otherwise result from urine wetness. Also, without it, S.D. would be unable to leave his home, isolated and unable to attend school or other activities, thus harming his mental health.
The Medicaid agency denied coverage, claiming that the disposable underwear was not medically necessary and was a non-medical supply not covered by the Medicaid program. At a fair hearing, an ALJ upheld the denial. S.D. successfully appealed to the federal district court, which held that the EPSDT laws are enforceable and that S.D. was entitled to Medicaid coverage for the incontinence supplies. See 2002 US Dist. LEXIS 23535 (E.D. La. Dec. 5, 2002). On appeal, the Fifth Circuit unanimously affirmed the District Court, holding that Louisiana is required to provide all Medicaid covered services to beneficiaries under 21 when they are necessary to correct or ameliorate a condition. The Court stated that
[t]he plain words of the state and the legislative history make evident that Congress intended that the health care, services, treatment and other measures that must be provided under the EPSDT program be determined by reference to federal law, not state preferences.
391 F.3d at 592.
It also ruled that the disposable incontinence underwear needed by S.D. is a covered Medicaid service under the category of home health services which includes supplies, equipment and appliances suitable use in the home. Id. at 595. Finally, the court rejected the states argument that Medicaid beneficiaries could not enforce the EPSDT requirements in court.
