Justia Health Law Opinion Summaries

The parents of a teenage girl (L.M.) sued Premera Blue Cross under the Employee Retirement Income Security Act (ERISA), claiming improper denial of medical benefits. L.M. experienced mental illness since she was a young girl. L.M. was eventually placed in Eva Carlston Academy, where she obtained long-term psychiatric residential treatment. For this treatment, the parents submitted a claim to Premera under the ERISA plan’s coverage for psychiatric residential treatment. Premera denied the claim ten days into L.M.’s stay. But Premera agreed to cover the first eleven days of L.M.’s treatment, explaining the temporary coverage as a "courtesy." The parents appealed the denial of subsequent coverage, and Premera affirmed the denial based on a physician's medical opinion. The parents filed a claim for reimbursement of over $80,000 in out-of-pocket expenses for L.M.’s residential treatment at the Academy. Both parties moved for summary judgment, and the district court granted summary judgment to Premera based on two conclusions: (1) Premera’s decision was subject to the arbitrary-and- capricious standard of review; and (2) Premera had not acted arbitrarily or capriciously in determining that L.M.’s residential treatment was medically unnecessary. The district court granted summary judgment to Premera, and the parents appealed. After review, the Tenth Circuit concluded the district court erred by applying the arbitrary-and-capricious standard and in concluding Premera had properly applied its criteria for medical necessity. Given these conclusions, the Court reversed and remanded the matter back to the district court for de novo reevaluation of the parents’ claim. View "M. v. Premera Blue Cross" on Justia Law

This appeal stemmed from a group of fourteen diversity cases that were consolidated by the Judicial Panel on Multidistrict Litigation and transferred to the Northern District of Oklahoma. The plaintiffs in all fourteen cases were cancer treatment providers who purchased multi-dose vials of Herceptin, a breast cancer drug, from defendant Genentech, Inc. (Genentech). Plaintiffs alleged that Genentech violated state law by failing to ensure that each vial of Herceptin contained the labeled amount of the active ingredient, and by misstating the drug concentration and volume on the product labeling. After the cases were consolidated, Genentech moved for summary judgment, arguing that plaintiffs’ claims were pre-empted by federal law. The district court agreed with Genentech and granted its motion for summary judgment. Plaintiffs appealed. The Tenth Circuit disagreed with the district court's conclusion that plaintiffs' claims were preempted, and consequently, reversed summary judgment and remanded for further proceedings. View "In re: MDL 2700 Genentech" on Justia Law

The insured, Brenda Sandoval, submitted a claim to her insurer, Unum Life Insurance Company of America, which initially paid benefits but then terminated them. The termination of benefits led Sandoval to sue Unum for: (1) a common-law tort (bad faith breach of insurance contract); (2) a statutory tort (unreasonable conduct under Colo. Rev. Stat. sec. 10-3-1115 to 1116); and (3) breach of contract. The district court granted Unum’s motion for partial summary judgment on the tort claims. The contract claim went to trial, where the jury rendered a verdict for Sandoval. The district court later denied Unum’s motion for judgment as a matter of law. Sandoval appealed the grant of Unum’s motion for partial summary judgment, and Unum cross-appealed the denial of its motion for judgment as a matter of law. After review, the Tenth Circuit affirmed the award of partial summary judgment on the tort claims because Unum conducted a reasonable investigation. On the contract claim, the Court also affirmed the denial of Unum’s motion for judgment as a matter of law: the policy contained two alternative tests for a disability, and the evidence permitted a reasonable finding that Sandoval had satisfied at least one of these definitions. View "Sandoval v. UNUM Life Insurance" on Justia Law

Stacey Janssen alleged Lawrence Memorial Hospital ("LMH") engaged in two healthcare schemes to fraudulently receive money from the United States. Janssen first contended LMH falsified patients’ arrival times in order to increase its Medicare reimbursement under certain pay-for-reporting and pay-for-performance programs the Government used to study and improve hospitals’ quality of care. Second, Janssen contended LMH falsely certified compliance with the Deficit Reduction Act in order to receive Medicare reimbursements to which it was otherwise not entitled. LMH moved for summary judgment below, arguing Janssen failed to show her allegations satisfied the Act’s materiality requirement - that the alleged falsehoods influenced the Government’s payment decision as required under the FCA. The district court granted LMH summary judgment on all of Janssen’s claims on this basis, and finding no reversible error, the Tenth Circuit affirmed. View "United States ex rel. Janssen v. Lawrence Memorial Hospital" on Justia Law

Marques Davis was an inmate at the Hutchinson Correctional Facility (“HCF”) from June 2016 until his death in April 2017. During the course of his confinement, Davis suffered from constant neurological symptoms, the cause of which went untreated by HCF medical personnel. When he eventually died from Granulomatous Meningoencephalitis, Davis’s estate (“the Estate”) brought federal and state law claims against Corizon Health, Inc. and numerous health care professionals who interacted with Davis during his incarceration. One such medical professional, Dr. Sohaib Mohiuddin, filed a qualified-immunity-based motion to dismiss the Estate’s 42 U.S.C. 1983 claim. The district court denied the motion, concluding the complaint set out a clearly established violation of Davis’s right to be free from deliberate indifference to the need for serious medical care. Mohiuddin appealed, arguing the district court erred in determining the complaint’s conclusory and collective allegations stated a valid Eighth Amendment claim as to him. Upon de novo review, the Tenth Circuit concluded the complaint did not state a valid deliberate indifference claim as to Mohiuddin. Thus, it reversed the denial of Mohiuddin’s motion to dismiss and remanded the matter to the district court for further proceedings. View "Walker v. Corizon Health" on Justia Law

Among its reforms, the Patient Protection and Affordable Care Act (“ACA”) required private health insurers to provide coverage for individuals regardless of their gender or health status, including preexisting conditions. Congress anticipated these reforms might hamper the ability of insurers to predict health care costs and to price health insurance premiums as more individuals sought health insurance. To spread the risk of enrolling people who might need more health care than others, Congress established a risk adjustment program for the individual and small group health insurance markets. Congress tasked the Department of Health and Human Services (“HHS”) with designing and implementing this risk adjustment program with the states. HHS developed a formula to calculate how much each insurer would be charged or paid in each state. The formula relied on the “statewide average premium” to calculate charges and payments. Plaintiff-Appellee New Mexico Health Connections (“NMHC”), an insurer that was required to pay charges under the program, sued the HHS Defendants-Appellants under the Administrative Procedure Act (“APA”), alleging that HHS’s use of the statewide average premium to calculate charges and payments in New Mexico from 2014 through 2018 was arbitrary and capricious. The district court granted summary judgment to NMHC, holding that HHS violated the APA by failing to explain why the agency chose to use the statewide average premium in its program. It remanded to the agency and vacated the 2014, 2015, 2016, 2017, and 2018 rules that implemented the program. After the district court denied HHS’s motion to alter or amend judgment under Federal Rule of Civil Procedure 59(e), HHS appealed. The Tenth Circuit Court of Appeals: (1) determined NMHC’s claims regarding the 2017 and 2018 rules were moot, so the matter was remanded to the district court to vacate its judgment on those claims and dismiss them as moot; (2) reversed the district court’s grant of summary judgment to NMHC as to the 2014, 2015, and 2016 rules because it determined HHS acted reasonably in explaining why it used the statewide average premium in the formula. Because the Court reversed the district court on its summary judgment ruling in favor of NMHC, it did not address the denial of HHS’s Rule 59(e) motion. View "New Mexico Health Connections v. HHS" on Justia Law

Cameo Williams, Sr. was a veteran of the United States Army, who spent his entire service stateside - never overseas or in combat. But for years, based on false statements about combat service, he obtained VA benefits for combat-related PTSD. The issue presented for the Tenth Circuit Court of Appeals in this case was whether it mattered about Williams’ lies about overseas service to obtain his PTSD benefits. The Court rejected Williams’s argument that his lie was not material under 18 U.S.C. 1001(a)(2), as well as his two challenges to evidentiary rulings. View "United States v. Williams" on Justia Law

Blue Valley Hospital, Inc., (“BVH”) appealed a district court’s dismissal of its action for lack of subject matter jurisdiction. The Department of Health and Human Services (“HHS”) and the Centers for Medicare and Medicaid Services (“CMS”) terminated BVH’s Medicare certification. The next day, BVH sought an administrative appeal before the HHS Departmental Appeals Board and brought this action. In this action, BVH sought an injunction to stay the termination of its Medicare certification and provider contracts pending its administrative appeal. The district court dismissed, holding the Medicare Act required BVH exhaust its administrative appeals before subject matter jurisdiction vested in the district court. BVH acknowledged that it did not exhaust administrative appeals with the Secretary of HHS prior to bringing this action, but argued: (1) the district court had federal question jurisdiction arising from BVH’s constitutional due process claim; (2) BVH’s due process claim presents a colorable and collateral constitutional claim for which jurisdictional exhaustion requirements are waived under Mathews v. Eldridge, 424 U.S. 319 (1976); and (3) the exhaustion requirements foreclosed the possibility of any judicial review and thus cannot deny jurisdiction under Bowen v. Michigan Academy of Family Physicians, 476 U.S. 667 (1986). The Tenth Circuit disagreed and affirmed dismissal. View "Blue Valley Hospital v. Azar" on Justia Law

A federal grand jury indicted Steven DeLia on one count of healthcare fraud. But the government filed the indictment outside the ordinarily applicable statute of limitations. Notwithstanding this filing, the government argued the indictment was timely because: (1) the Wartime Suspension of Limitations Act suspended the limitations period from running in this case; and (2) DeLia waived his asserted statute-of-limitations defense. The Tenth Circuit rejected both reasons and concluded the prosecution was time-barred. DeLia’s conviction was vacated and the indictment was dismissed. View "United States v. DeLia" on Justia Law

This appeal presented a question of whether established law supported Plaintiff Joseph Leiser's claim that two jail officials in Coffey County, Kansas, violated his constitutional rights by disclosing medical information about him that they had properly obtained. Plaintiff was set to be extradited from Illinois to Kansas, and the Kansas jail requested Illinois arrange for multiple medical examinations of Plaintiff to determine whether he had suffered injuries after being tasered by U.S. Marshals. The Kansas official learned Plaintiff had bone lesions and possibly cancer. This information was conveyed to the Coffey County Sheriff, who conveyed it to Coffey County Hospital, then to Plaintiff's family and friends, without first obtaining Plaintiff's permission. The Tenth Circuit determined the prison officials were entitled to qualified immunity, and dismissed his case. View "Leiser v. Moore" on Justia Law