Justia Health Law Opinion Summaries

Plaintiff-Appellant E.W. was a participant in an employer-sponsored health insurance plan governed by the Employee Retirement Income Security Act of 1974 (“ERISA”). E.W.’s daughter, Plaintiff-Appellant I.W., was a beneficiary of E.W.’s plan. From September 2016 through December 2017, I.W. received treatment in connection with mental health challenges and an eating disorder at Uinta Academy (“Uinta”), an adolescent residential treatment center in Utah. In January 2017, Defendants-Appellees Health Net Insurance Company and Health Net of Arizona, Inc. began covering I.W.’s treatment under E.W.’s ERISA plan (the “Plan”). Effective February 23, 2017, Health Net determined I.W.’s care at Uinta was no longer medically necessary, and it denied coverage from that day forward. In assessing whether to discontinue coverage, Health Net applied the McKesson InterQual Behavioral Health 2016.3 Child and Adolescent Psychiatry Criteria. Health Net determined I.W. did not satisfy the InterQual Criteria within the relevant period and notified Plaintiffs in a letter dated March 1, 2017. Plaintiffs allegedly did not receive Health Net’s March 2017 denial letter, and I.W. remained at Uinta until December 2017, when she was formally discharged. After receiving notice in May 2018 that Health Net had denied coverage effective February 23, 2017, Plaintiffs appealed the decision. Health Net again determined I.W. did not satisfy the InterQual Criteria during the relevant period and upheld its initial denial. Plaintiffs then appealed to an external reviewer, which upheld the decision to deny coverage. Health Net moved to dismiss plaintiffs' legal claims under ERISA and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”). The district court denied Plaintiffs’ motion and granted summary judgment to Health Net. After review, the Tenth Circuit affirmed the district court’s decision granting summary judgment to Health Net on Plaintiffs’ ERISA claim; the Court reversed the finding Plaintiffs failed to state a claim under MHPAEA; and the case was remanded for further proceedings. View "W., et al. v. Health Net Life Insurance Company, et al." on Justia Law

In 2019, the Oklahoma legislature unanimously passed the Patient’s Right to Pharmacy Choice Act. In response to the Act’s passage, the Pharmaceutical Care Management Association (PCMA), a trade association representing PBMs, sued to invalidate the Act, alleging that the Employee Retirement Income Security Act of 1974 (ERISA), and Medicare Part D, preempted the Act. The district court ruled that ERISA did not preempt the Act but that Medicare Part D preempted six of the thirteen challenged provisions. PCMA appealed the court’s ERISA ruling on four provisions of the Act and the court’s Medicare Part D ruling on one provision. After its review, the Tenth Circuit determined ERISA and Medicare Part D preempted the four challenged provisions, and therefore reversed. View "Pharmaceutical Care v. Mulready, et al." on Justia Law

Plaintiffs David P. and his daughter L.P. sought to recover health care benefits under a medical plan David P. obtained through his employer. The district court awarded Plaintiffs benefits, determining that the manner in which Defendants processed Plaintiffs’ claims for coverage violated ERISA. The Tenth Circuit Court of Appeals agreed: Defendants’ deficient claims processing circumvented the dialogue ERISA mandates between plan participants claiming benefits and the plan administrators processing those benefits claims. The Court disagreed, however, with the district court as to the appropriate remedy for the violations of ERISA’s claims-processing requirements at issue here. "Rather than outright granting Plaintiffs their claimed benefits, we conclude, instead, that Plaintiffs’ claims for benefits should be remanded to Defendants for proper consideration." The case was remanded to the district court with directions to remand Plaintiffs’ benefits claims to Defendants. View "P., et al. v. United Healthcare Insurance, et al." on Justia Law

Middle schooler A.K. struggled with suicidal ideation for many years and attempted suicide numerous times, resulting in frequent emergency room visits and in-patient hospitalizations. A.K.’s physicians strongly recommended she enroll in a residential treatment facility to build the skills necessary to stabilize. Despite these recommendations and extensive evidence in the medical record, United Behavioral Health (“United”) denied coverage for A.K.’s stay at a residential treatment facility beyond an initial three month period. Her parents appealed United’s denial numerous times, requesting further clarification, and providing extensive medical evidence, yet United only replied with conclusory statements that did not address the evidence provided. As a result, A.K.’s parents brought this lawsuit contending United violated its fiduciary duties by failing to provide a “full and fair review” of their claim for medical benefits. Both sides moved for summary judgment, and the district court ruled against United. The issue this case presented for the Tenth Circuit's review was whether United arbitrarily and capriciously denied A.K. medical benefits and whether the district court abused its discretion in awarding A.K. benefits rather than remanding to United for further review. The Court ultimately concluded United did act arbitrarily and capriciously in not adequately engaging with the opinions of A.K.’s physicians and in not providing its reasoning for denials to A.K.’s parents. The Court also concluded the district court did not abuse its discretion by awarding A.K. benefits outright. View "D.K., et al. v. United Behavioral Health, et al." on Justia Law

Michelle Caddell died from cervical cancer while in custody as a pretrial detainee in the Tulsa County Jail. Yolanda Lucas, as special administrator of decedent Caddell’s estate, initiated this case under 42 U.S.C. § 1983 bringing claims of deliberate indifference in violation of the Eighth and Fourteenth Amendments against Dr. Gary Myers and against Turn Key Health Clinics, LLC (“Turn Key”) and Sheriff Vic Regalado in his official capacity through municipal liability, violations of the Equal Protection clause against Turn Key and Sheriff Regalado, and negligence and wrongful death under Oklahoma state law against Dr. Myers and Turn Key. The three Defendants individually moved to dismiss all claims and the district court granted the motions. On appeal, Plaintiff challenged the district court’s determinations that she failed to plausibly allege: (1) deliberate indifference to serious medical needs against Dr. Myers; (2) municipal liability against Turn Key and Sheriff Regalado; and (3) violation of the Equal Protection clause against Turn Key and Sheriff Regalado. She also challenged the finding that Dr. Myers and Turn Key were entitled to immunity for the state law claims under the Oklahoma Governmental Tort Claims Act (“OGTCA”). The Tenth Circuit found it would need to determine the OGTCA's applicability to private corporations (and their employees) that contract with the state to provide medical services at the summary judgment stage if the factual record is sufficiently developed and the facts are uncontroverted. Accordingly, the Court reversed as premature the district court’s decision that Turn Key and Dr. Myers were immune under the OGTCA. The Court affirmed in all other respects. View "Lucas v. Turn Key Health Clinics, et al." on Justia Law

When Plaintiff-appellant Linda Smith purchased a prescribed continuous blood glucose monitor (CGM) and its necessary supplies between 2016 and 2018, she sought reimbursement through Medicare Part B. Medicare administrators denied her claims. Relying on a 2017 ruling issued by the Centers for Medicare and Medicaid Services (CMS), Medicare concluded Smith’s CGM was not “primarily and customarily used to serve a medical purpose” and therefore was not covered by Part B. Smith appealed the denial of her reimbursement claims through the multistage Medicare claims review process. At each stage, her claims were denied. Smith then sued the Secretary of the Department of Health and Human Services in federal court, seeking monetary, injunctive, and declaratory relief. Contending that her CGM and supplies satisfied the requirements for Medicare coverage. Instead of asking the court to uphold the denial of Smith’s claims, the Secretary admitted that Smith’s claims should have been covered and that the agency erred by denying her claims. Rather than accept the Secretary’s admission, Smith argued that the Secretary only admitted error to avoid judicial review of the legality of the 2017 ruling. During Smith’s litigation, CMS changed its Medicare coverage policy for CGMs. Prompted by several adverse district court rulings, CMS promulgated a formal rule in December 2021 classifying CGMs as durable medical equipment covered by Part B. But the rule applied only to claims for equipment received after February 28, 2022, so pending claims for equipment received prior to that date were not covered by the new rule. Considering the new rule and the Secretary’s confession of error, the district court in January 2022 remanded the case to the Secretary with instructions to pay Smith’s claims. The district court did not rule on Smith’s pending motions regarding her equitable relief claims; instead, the court denied them as moot. Smith appealed, arguing her equitable claims were justiciable because the 2017 ruling had not been fully rescinded. The Tenth Circuit agreed with the Secretary that Smith’s claims were moot: taken together, the December 2021 final rule and the 2022 CMS ruling that pending and future claims for CGMs would be covered by Medicare deprived the Tenth Circuit jurisdiction for further review. View "Smith v. Becerra" on Justia Law

Three teaching hospitals challenged the denial of Medicare reimbursements. At that time, a teaching hospital could obtain reimbursement only by incurring “substantially all” of a resident’s training costs. Because the teaching hospitals had shared the training costs for each resident, the government denied reimbursement. The denials led the teaching hospitals to file administrative appeals. While they were pending, Congress enacted the Affordable Care Act (ACA), which created a new standard for reimbursement. The parties disagreed on whether the ACA’s new standard applied to proceedings reopened when Congress changed the law. The agency answered no, and the district court granted summary judgment to the agency. Finding no reversible error in that decision, the Tenth Circuit affirmed. View "St. Francis Hospital, et al. v. Becerra" on Justia Law

Defendant-appellant Adam Hemmelgarn moved for compassionate release, based on an outbreak of COVID-19 at FCI Lompoc. The district court denied his motion, as well as his subsequent motion for reconsideration. The Tenth Circuit affirmed, concluding the district court did not abuse its discretion in deciding Hemmelgarn had not established extraordinary and compelling reasons in support of a sentence reduction because of his health conditions or the risk of exposure to COVID-19. View "United States v. Hemmelgarn" on Justia Law

At the time this appeal was initiated, Jason Brooks was a Colorado-state inmate serving a lengthy prison sentence for securities fraud. Brooks had an extreme and incurable case of ulcerative colitis: even when his disease was well treated, Brooks suffered from frequent, unpredictable fecal incontinence. This case involved the Colorado Department of Corrections’s (“CDOC”) efforts, or lack thereof, to deal with the impact of Brooks’s condition on his ability to access the prison cafeteria. Specifically, the issues presented centered on whether the district court erred when it concluded: (1) Brooks’s Americans with Disabilities Act (“ADA”) claim for damages failed because the CDOC’s offer to provide Brooks with adult diapers was a reasonable accommodation of Brooks’s disability; and (2) Brooks’s Eighth Amendment claim against ADA Inmate Coordinator Julie Russell failed because the decision not to access the cafeteria with the use of adult diapers was Brooks’s alone. The Tenth Circuit Court of Appeals determined the district court erred in its treatment of Brooks’s ADA claim for damages. "A reasonable juror could conclude the offer of adult diapers was not a reasonable accommodation of Brooks’s disability. Thus, at least as to the question of the reasonableness of the proposed accommodation, the district court erred in granting CDOC summary judgment on Brooks’s ADA claim for damages." On the other hand, the Court concluded the district court correctly granted summary judgment in favor of Russell on Brooks’s Eighth Amendment claim: "the record is devoid of sufficient evidence for a jury to find Russell acted with a sufficiently culpable state of mind—deliberate indifference to Brooks’s ability to access food—when she declined Brooks’s request for a movement pass." Accordingly, the Court dismissed in part, reversed in part, and remanded this matter to the district court for further proceedings. View "Brooks v. CDOC, et al." on Justia Law

Wichita pharmacist Ebube Otuonye (defendant) filled prescriptions written by Dr. Steven Henson for opioids and other controlled substances. The Drug Enforcement Administration (“DEA”) became suspicious of Dr. Henson’s prescriptions and investigated him, which led them to Defendant Otuonye. Based on the results of the DEA’s investigation, Otuonye was indicted for conspiring to unlawfully distribute controlled substances; unlawfully distributing controlled substances; and Medicare and Medicaid fraud. A jury convicted Otuonye on all four counts. The district court imposed a 150-month concurrent prison sentence. Otuonye raised seven issues on appeal: five challenged the admission of evidence; the sixth challenged the sufficiency of the evidence for all four convictions; and in the last, Otuonye argued the district court committed procedural error by miscalculating his sentencing guidelines range. Finding none of these challenges availing, the Tenth Circuit affirmed his conviction and sentence. View "United States v. Otuonye" on Justia Law