## Facts

- S.D., a 16-year-old Medicaid-eligible child, had severe disabilities including spina bifida, total bowel and bladder incontinence, and lack of sensation below the waist, creating recurring risks of skin breakdown and infection.
- S.D. qualified for Medicaid benefits and was eligible for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services for individuals under 21.
- In 2002, S.D.’s physician prescribed disposable incontinence underwear as medically necessary to draw moisture away from the skin and prevent chronic irritation and infection.
- Louisiana’s Medicaid agency denied coverage, asserting the item was not “medically necessary” and was not covered (and was categorically excluded) under the state Medicaid plan.
- An administrative law judge upheld the denial based on the state exclusion.
- S.D., through his next friend, sued under 42 U.S.C. § 1983, alleging the denial violated the Medicaid Act’s EPSDT requirements.
- The district court ordered Louisiana to provide the prescribed item, concluding EPSDT requires coverage of medically necessary services to “correct or ameliorate” a child’s conditions even if not listed in the state plan; the state appealed.

## Issues

1. Whether the Medicaid Act’s EPSDT provisions required Louisiana Medicaid to provide medically prescribed disposable incontinence underwear as treatment necessary to “correct or ameliorate” S.D.’s condition, regardless of state-plan coverage or exclusions.
2. Whether the relevant EPSDT provisions create an individual federal right enforceable by a Medicaid beneficiary under 42 U.S.C. § 1983.

## Decision

- The Fifth Circuit affirmed the district court.
- The court held EPSDT required Louisiana Medicaid to furnish the prescribed disposable incontinence underwear because it was medically necessary to ameliorate S.D.’s condition and related health risks.
- The court held the EPSDT provisions at issue confer an individual federal right enforceable under § 1983.
- The court rejected reliance on state-plan limitations and categorical state exclusions as a basis to deny EPSDT-mandated, medically necessary treatment.

## Legal Principles

- EPSDT requires states to provide Medicaid-eligible individuals under age 21 with medically necessary services listed in the federal Medicaid service categories when needed to “correct or ameliorate” physical or mental conditions, whether or not those services are included in the state plan.
- “Ameliorate” includes measures that improve functioning or reduce harmful consequences of a condition, even if the condition cannot be cured.
- State Medicaid exclusions or coverage limits conflicting with EPSDT’s federal mandate cannot justify denial of medically necessary EPSDT services.
- EPSDT provisions using mandatory, beneficiary-focused language may create enforceable individual rights under § 1983 absent a congressional intent to foreclose that remedy.

## Conclusion

The Fifth Circuit required Louisiana Medicaid to cover medically necessary disposable incontinence underwear for an EPSDT-eligible child and held that the EPSDT mandate to provide corrective or ameliorative treatment creates an individual right enforceable through § 1983.


S.D. ex rel. Dickson v. Hood, 391 F.3d 581 (5th Cir. 2004)