Justia Health Law Opinion Summaries

Plaintiff filed a lawsuit in state court, alleging state law claims arising from SelectHealth’s administration of her deceased husband’s Medicare Advantage ("MA") plan and his death. SelectHealth removed the action to federal court on the basis of diversity jurisdiction.The court first considered whether Plaintiff’s claims must be exhausted through the Medicare Act’s administrative review scheme. The court concluded that Plaintiff’s claims were not subject to the SSA’s exhaustion requirement because the dispute was not whether Plaintiff’s husband received a favorable outcome from the internal benefits determination process but rather whether he should have received the services earlier.Next, the court held that Plaintiff’s claim that SelectHealth breached a duty to process her husband’s October 7, 2016 appeal was expressly preempted. The court reasoned that the Medicare Act preempted those claims, regardless of whether they would be inconsistent with federal regulations. The court also held that the Medicare Act also preempted Plaintiff’s claims based on SelectHealth’s alleged breach of duty to investigate properly her husband’s August 23, 2016 preauthorization request for consultation and testing at the Medical Center in Phoenix, Arizona.The court concluded that a state law claim based on a duty to process claims for benefit in a timely manner is preempted by the Part C regulations that set forth the timeframes for initial determinations and reconsideration decisions. The court affirmed the district court’s summary judgment in favor of SelectHealth because the Medicare Act’s express preemption provision barred her claims. View "NAOMI AYLWARD V. SELECTHEALTH, INC." on Justia Law

Global Rescue Jets, which does business as Jet Rescue, billed Kaiser at Jet Rescue’s usual and customary rates. Kaiser paid only a fraction of the billed amount, however, because in its view Jet Rescue’s services were covered by Medicare and thus subject to payment at the much lower Medicare-approved rates. Jet Rescue brought this action against Kaiser to recover the additional sums Kaiser allegedly owes. Jet Rescue argues that it was not required to exhaust administrative remedies before filing suit and that the exhaustion requirement should have been excused in any eventThe circuit court affirmed the district court’s dismissal, reasoning original Medicare beneficiaries must exhaust their administrative remedies before seeking judicial review of a claim for benefits. The panel also rejected Jet Rescue’s contention that the exhaustion requirement should be excused. The panel held that the exhaustion requirement may be excused if three conditions are satisfied: (1) the plaintiff’s claim is wholly collateral to a claim for Medicare benefits; (2) the plaintiff has made a colorable showing of irreparable harm; and (3) exhaustion would be futile. The panel concluded that Jet Rescue failed to meet the first and third requirements. Thus, the circuit court rejected both arguments and affirmed the district court’s judgment. View "GLOBAL RESCUE JETS, LLC V. KAISER FOUNDATION HEALTH PLAN" on Justia Law

Relatives of Saldana, who died from COVID-19 at Glenhaven nursing home, sued Glenhaven in California state court, alleging state-law causes of action. Glenhaven removed the case to federal court. The Ninth Circuit affirmed a remand to state court,The district court lacked jurisdiction under the federal officer removal statute, 28 U.S.C. 1442, because Glenhaven did not act under a federal officer or agency’s directions when it complied with mandatory directives from the Centers for Medicare and Medicaid Services, the Centers for Disease Control and Prevention, and the Department of Health and Human Services.The claims were not completely preempted by the Public Readiness and Emergency Preparedness Act, which provides immunity from suit when the HHS Secretary determines that a threat to health constitutes a public health emergency, but provides an exception for an exclusive federal cause of action for willful misconduct. A March 2020 declaration under the Act provided "liability immunity for activities related to medical countermeasures against COVID-19.” The Act does not displace non-willful misconduct claims related to the public health emergency, nor did it provide substitute causes of action. The federal scheme was not so comprehensive that it entirely supplanted state law claims.The district court did not have jurisdiction under the embedded federal question doctrine, which applies if a federal issue is necessarily raised, actually disputed, substantial, and capable of resolution in federal court without disrupting the federal-state balance approved by Congress. View "Saldana v. Glenhaven Healthcare LLC" on Justia Law

Through a bankruptcy proceeding, Bristol became the successor-in-interest to Haven, an accredited mental-health and substance-abuse treatment center that regularly serviced patients insured by Cigna. Bristol alleged that Cigna violated the Employee Retirement Income Security Act of 1974 (ERISA) and state law by denying Haven’s claims for reimbursement for services provided. Haven was out-of-network for Cigna’s insureds. The district court dismissed Bristol’s ERISA claim, as an assignee of a healthcare provider, for lack of derivative standing, or lack of authority to bring a claim under ERISA, 29 U.S.C. 1132(a)(1)(B).The Ninth Circuit reversed. Under ERISA, a non-participant health provider cannot bring claims for benefits on its own behalf but must do so derivatively, relying on its patients’ assignments of their benefits claims. Other assignees also may have derivative standing if extending standing would align with the goal of ERISA. Refusing to allow derivative standing for Bristol would create serious perverse incentives that would undermine the goal of ERISA. Denying derivative standing to health care providers would harm participants or beneficiaries because it would discourage providers from becoming assignees and possibly from helping beneficiaries who were unable to pay up-front. View "Bristol SL Holdings, Inc. v. Cigna Health and Life Insurance Co." on Justia Law

Pacheco received Depo-Provera injections from NeighborCare, a federally-qualified community health center. Depo-Provera is a highly effective contraceptive that requires injections every 11-13 weeks. Pacheco visited NeigborCare in September 2011, for an “on-time” injection. A NeighborCare employee instead injected Pacheco with a flu vaccine. Pacheco alleges that she did not consent to a flu shot and did not learn that she received a flu shot instead of her scheduled injection until she called NeighborCare for her next injection. Pacheco's child, S.L.P., was born with epilepsy and bilateral perisylvian polymicrogyria, which contributes to neurological delays.The district court found that Rodriguez failed to meet the minimum standard of care and that the unwanted pregnancy, birth, and medical expenses associated with S.L.P.'s condition were foreseeable consequences caused by the negligence and awarded $10,042,294.81.The Ninth Circuit noted that the negligently performed procedure here was not “intended to prevent the birth of a defective child,” but to “prevent the birth of an unwanted child,” so this case lies outside the duty imposed on healthcare providers to assume responsibility when they encumber parents’ rights by failing to adequately complete procedures to prevent the births of defective children. The court certified the question to the Washington Supreme Court: Under claims for wrongful birth or wrongful life, does Washington law allow extraordinary damages for costs associated with raising a child with birth defects when defendants negligently provided contraceptive care even though plaintiffs did not seek contraceptives to prevent conceiving a child later born with birth defects? View "Pacheco v. United States" on Justia Law

A 16-year-old high school student and her parents filed an emergency motion for an injunction pending appeal, seeking to enjoin the school district from requiring compliance with a student vaccination mandate. The Ninth Circuit granted plaintiffs' motion in part. The court ordered that an injunction shall be in effect only while a "per se" deferral of vaccination is available to pregnant students under the school district's student vaccination mandate, and that the injunction shall terminate upon removal of the per se deferral option for pregnant students. Defendants then filed a letter and supporting declaration explaining that the deferral option for pregnant students has been removed from the mandate. Given the removal of the per se deferral option for pregnant students, the injunction issued in the November 28, 2021 order has terminated under its own terms.The Ninth Circuit issued an order providing its reasoning for why an injunction pending appeal is not warranted as to the now-modified student vaccination mandate. The court concluded that plaintiffs have not demonstrated a sufficient likelihood of success in showing that the district court erred in applying rational basis review, as opposed to strict scrutiny, to the student vaccination mandate. The court explained that plaintiffs' emergency motion fails to raise a serious question as to whether the vaccination mandate is not neutral and generally applicable; plaintiffs have not demonstrated a likelihood of success in showing that the district court erred by applying rational basis review; and plaintiffs do not argue that they are likely to succeed on the merits of their free exercise claim if rational basis review applies. The court also concluded that plaintiffs have not carried their burden of establishing that they will suffer irreparable harm if this court does not issue an injunction, or that the public interest weighs in their favor. View "Doe v. San Diego Unified School District" on Justia Law

In April 2020, the district court entered a preliminary injunction and provisionally certified nationwide subclasses of ICE detainees with risk factors or disabilities placing them at heightened risk of severe illness and death from COVID-19. The court found that plaintiffs were likely to succeed on claims of deliberate indifference to the medical needs of detainees, punitive conditions of confinement, and violation of the Rehabilitation Act, 29 U.S.C. 794. The preliminary injunction imposed a broad range of obligations on the federal government.The Ninth Circuit reversed, stating that neither the facts nor the law supported a judicial intervention of this magnitude. The plaintiffs did not make a clear showing that ICE acted with deliberate indifference to medical needs or in reckless disregard of health risks. If a particular condition or restriction of pretrial detention is reasonably related to a legitimate governmental objective, it does not, alone, amount to punishment; there was a legitimate governmental objective here, ICE was holding detainees because they were suspected of having violated the immigration laws or were otherwise removable. ICE’s national directives did not create excessive conditions of “punishment.” Rejecting the Rehabilitation Act claim, the court stated that the plaintiffs at most demonstrated that they were subjected to inadequate national policies; they did not show they were treated differently from other detainees “solely by reason” of their disabilities. View "Fraihat v. United States Immigration and Customs Enforcement" on Justia Law

Porretti, a 62-year-old prisoner, has suffered from serious mental illnesses—Tourette’s syndrome, depression, obsessive-compulsive disorder, personality disorder, and paranoid schizophrenia— throughout his life. Porretti’s mental illnesses have caused him to attempt suicide and to suffer psychotic symptoms, including compulsive ingestion of metal objects like razor blades, paranoid delusions, hallucinations, and verbal tics. Porretti received Wellbutrin and Seroquel for his mental illnesses before he was incarcerated in Nevada and after he entered into the custody of the Nevada Department of Corrections (NDOC). In 2017, without the recommendation of a healthcare provider, NDOC stopped providing his medication because of a new administrative policy.The Ninth Circuit upheld a preliminary injunction requiring prison officials to provide Porretti’s Wellbutrin and Seroquel. The district court carefully applied the preliminary-injunction factors and rendered highly detailed factual findings that rejected opinions from NDOC’s experts for reasons grounded in the record evidence; Porrettif’s Eighth Amendment claim was likely to succeed on the merits and he would suffer irreparable harm in the form of “very serious or extreme damage to his mental health” if injunctive relief were not granted. Porretti’s severe and persistent psychotic symptoms overwhelmingly outweighed NDOC’s financial or logistical burdens in providing Wellbutrin and Seroquel. An injunction was in the public’s interest because prisons must comply with the standard of care mandated by the Eighth Amendment. View "Porretti v. Dzurenda" on Justia Law

The Ninth Circuit reversed the district court's grant of summary judgment in favor of Agendia in an action alleging that the HHS wrongfully denied its claims for reimbursement for diagnostic tests under the Medicare health insurance program. Agendia contends that the denial was improper because the local coverage determination was issued without notice and opportunity for comment in violation of a provision of the Medicare Act—specifically, 42 U.S.C. 1395hh.The panel held that section 1395hh's notice-and-comment requirement does not apply to local coverage determinations, and that the district court erred in interpreting the statute otherwise. The panel rejected Agendia's alternative argument that the Medicare Act and its implementing regulations have unconstitutionally delegated regulatory authority to Medicare contractors by permitting them to issue local coverage determinations. The panel held that, because those contractors act subordinately to the HHS officials implementing Medicare, there is no unconstitutional delegation. View "Agendia, Inc. v. Becerra" on Justia Law

The Ninth Circuit affirmed the district court's grant of summary judgment for HHS in an action brought by plaintiff, challenging HHS's denial of his claim for reimbursement from the Medicare program for services that he provided covered patients. The Supreme Court recently reaffirmed that a reviewing court should defer to an agency's reasonable interpretation of ambiguous regulations in Kisor v. Wilkie, 139 S. Ct. 2400 (2019).The panel agreed with the district court that the governing regulation, 42 C.F.R. 424.520(d), is genuinely ambiguous and that the agency's interpretation is reasonable. In this case, section 424.520(d) does not specify whether a certification submitted to reactivate billing privileges constitutes a "Medicare enrollment application" that triggers a new effective date. The panel concluded that the Board's interpretation of section 424.520(d) merits Auer deference and controls this case. Therefore, plaintiff's reactivation request was "a Medicare enrollment application," and its filing date of August 31, 2015 is the effective date of his billing privileges. The panel also agreed with the district court that its review was appropriately confined to the administrative record the agency produced and that the agency was not required to supplement the record. View "Goffney v. Becerra" on Justia Law