Justia Health Law Opinion Summaries

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

Shawna Tanner, the plaintiff below, appealed an adverse ruling on summary judgment. Tanner was approximately 35 weeks pregnant and in custody at the Metropolitan Detention Center in Bernalillo County, New Mexico when she went into the final stages of her pregnancy. Over the ensuing thirty hours, commencing with the point at which her water broke, Appellees—employees of a nationwide private medical contractor—ignored and minimized her symptoms, refused to transport her to a hospital, and failed to conduct even a cursory pelvic examination. Only minimal attention was given to her: water, Tylenol, and sanitary pads. After thirty hours of pain and trauma, Tanner gave birth to her son. The child was born with his umbilical cord wrapped around his neck. He was not breathing. He had no pulse. This appeal considered whether full-time employees of a for-profit, multi-state corporation organized to provide contract medical care in detention facilities may assert a qualified immunity defense to shield themselves from 42 U.S.C. 1983 liability. The Tenth Circuit found neither historical justifications of special government immunity nor modern policy considerations supported the extension of a qualified immunity defense to Appellees. Judgment was reversed and the matter remanded for further proceedings. View "Tanner v. McMurray" on Justia Law

This case arose from the tragic death of 21-year-old Madison Jensen while in custody of the Duchesne County Jail. Jensen was arrested after her father alerted law enforcement to her drug use and possession of drug paraphernalia. Her estate brought this action for deprivation of civil rights under color of state law. The district court granted summary judgment in favor of the county and qualified immunity to jail supervisors and staff, but denied qualified immunity to jail medical personnel, Defendants-Appellants (Nurse) Jana Clyde and Dr. Kennon Tubbs. The district court held that genuine issues of material fact precluded qualified immunity on the Estate’s claims of: (1) deliberate indifference to serious medical needs against Nurse Clyde; and (2) supervisory liability against Dr. Tubbs. The Tenth Circuit ultimately concluded that when an individual’s sole purpose was “to serve as a gatekeeper for other medical personnel,” and that person delays or refuses to fulfill the gatekeeper role, he may be liable for deliberate indifference. Clyde was the gatekeeper in this case, and she failed to fulfill that role when she chose to give Jensen Gatorade instead of calling Dr. Tubbs or PA Clark. Accordingly, Clyde was given sufficient notice that what she was doing violated Jensen’s rights to medical care. The Court affirmed as to Clyde and reversed as to Dr. Tubbs. View "Estate of Madison Jody Jensen v. Clyde" on Justia Law