Justia U.S. 4th Circuit Court of Appeals Opinion Summaries

Plaintiff, the Chapter 7 trustee for the bankruptcy estate of BioniCare Medical Technologies, contested determinations of the Medicare Appeals Council (MAC) refusing to provide coverage for the BIO-1000, a device to treat osteoarthritis of the knee. Plaintiff alleged that the Secretary improperly used the adjudicative process to create a policy of denying coverage for the BIO-1000, that the MAC's decisions were not supported by substantial evidence, and that the MAC's decisions were arbitrary and capricious on account of a variety of procedural errors. The court rejected those contentions and affirmed the judgment of the district court. View "Almy v. Sebelius" on Justia Law

This appeal arose from the district court's order granting final judgment to the United States upon equitable claims of payment by mistake of fact and unjust enrichment against Tuomey arising out of alleged violations of the Social Security Act, 42 U.S.C. 1395nn, (the Stark Law), and awarding damages plus pre- and post-judgment interest. Because the court concluded that the district court's judgment violated Tuomey's Seventh Amendment right to a jury trial, the court vacated the judgment and remanded for further proceedings. Because the court was remanding the case, the court also addressed other issues raised on appeal that were likely to recur upon retrial. View "Drakeford v. Tuomey Healthcare System" on Justia Law

Plaintiff, a minor, sustained serious injuries at birth due to the negligence of medical professionals who attended her delivery. As a result of plaintiff's injuries, DHHS, through the state Medicaid program, paid more than $1.9 million in medical and health care expenses on her behalf. Plaintiff instituted a medical malpractice action in state court and eventually settled the action for a lump some of approximately $2.8 million. The settlement agreement did not allocate separate amounts for past medical expenses and other damages. DHHS subsequently asserted a statutory lien on the settlement proceedings pursuant to N.C. Gen. Stat 108A-57 and 59 (third-party liability statues), which asserted that North Carolina had a subrogation right and could assert a lien upon the lesser of its actual medical expenditures or one-third of the medicaid recipient's total recovery. Plaintiff brought the instant action seeking declaratory and injunctive relief pursuant to 42 U.S.C. 1983, seeking to forestall payment under federal Medicaid law known as the "anti-lien provision," 42 U.S.C. 1396p. The court was persuaded that the unrebuttable presumption inherent in the one-third cap on the state's recovery imposed by the North Carolina third-party liability statutes was in fatal conflict with federal law. Accordingly, the court vacated the judgment in favor of the Secretary and remanded for further proceedings. View "E.M.A v. Cansler" on Justia Law

Plaintiff brought an action alleging that his dismissal from medical school for unprofessional behavior violated the Rehabilitation Act of 1973, 29 U.S.C. 794, and the Americans with Disabilities Act (ADA), 42 U.S.C. 12182. The district court granted summary judgment in favor of the medical school and plaintiff appealed. Because the court agreed with the district court that, with or without a reasonable accommodation of plaintiff's ADHD and anxiety disorder, plaintiff was not "otherwise qualified" to participate in the medical school's program, the court affirmed the judgment. View "Halpern v. Wake Forest Univ. Health" on Justia Law

This case involved a widow's claim for survivors' benefits under the Black Lung Benefits Act (BLBA), 30 U.S.C. 901-944, as amended by the the Patient Protection and Affordable Care Act (PPACA), Pub. L. No. 111-148, Section 1556, 124 Stat. 119, 260. The PPACA amendments revived Section 422(l) of the BLBA, 30 U.S.C. 932(l), which provided that an eligible survivor of a miner who was receiving benefits at the time of his death was automatically entitled to survivors' benefits without having to establish that the miner's death was due to pneumoconiosis. Relying on an amended section 932(l), the Benefits Review Board, ruled that the miner's widow was entitled to survivors' benefits. On appeal, petitioner raised a variety of constitutional and statutory challenges to the PPACA's restoration provision. The court held that because retroactive application of amended Section 932(l) was hardly arbitrary or irrational, petitioner's substantive due process argument was unavailing. Because amended Section 932(l) merely required petitioner to pay money - and thus did not infringe a specific, identifiable property interest - the Takings Clause was not applicable. The court also held that the miner's widow was derivatively entitled to survivors' benefits pursuant to Section 932(l). Finally, because petitioner made its contention, that 30 U.S.C. 901, 921(a), and 922(a)(2) prevented the miner's widow from receiving automatic survivors' benefits, for the first time at oral argument, the court held that it was waived. Accordingly, the judgment of the Board was affirmed. View "West Virginia CWP Fund v. Stacy" on Justia Law

The Commonwealth of Virginia brought suit against the Secretary of the Department of Health and Human Services, challenging one provision of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119, as an unconstitutional exercise of congressional power. Virginia maintained that the conflict between this provision and a newly-enacted Virginia statute provided it with standing to pursue this action. The court held that Virginia, as the sole plaintiff here, lacked standing to bring this action because the challenged provision, the individual mandate, imposed no obligation on Virginia and the Virginia statute did not confer on Virginia a sovereign interest in challenging the individual mandate. Accordingly, the court vacated the judgment of the district court and remanded with instructions to dismiss the case for lack of subject-matter jurisdiction.

Plaintiffs brought this suit to enjoin, as unconstitutional, enforcement of two provisions of the recently-enacted Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119. The challenged provisions amended the Internal Revenue Code by adding: (1) a "penalty" payable to the Secretary of the Treasury by an individual taxpayer who failed to maintain adequate health insurance coverage and (2) an "assessable payment" payable to the Secretary of the Treasury by a "large employer" if at least on of its employees received a tax credit or government subsidy to offset payments for certain health-related expenses. The court held that because this suit constituted a pre-enforcement action seeking to restrain the assessment of a tax, the Anti-Injunction Act, 28 U.S.C. 2283, stripped the court of jurisdiction. Accordingly, the court vacated the judgment of the district court and remanded the case with instructions to dismiss for lack of jurisdiction.

West Virginia sued pharmaceutical manufacturers, claiming that the defendants artificially inflated the reimbursement values of certain drugs, in violation of the West Virginia Consumer Credit and Protection Act, W. Va. Code 46A-1-101, and a state statute prohibiting fraud and abuse in the Medicaid program. The complaint alleged that the defendants inflated the average wholesale price of certain drugs and caused the state to pay an artificially inflated amount of reimbursement for the drugs. One company agreed to pay West Virginia $850,000. After learning of the settlement in 2007, the federal Centers for Medicare & Medicaid Services notified West Virginia of a disallowance in federal funding for the state’s Medicaid program for failure to credit the federal government its share of the settlement proceeds. The Appeals Board sustained the disallowance. The district court upheld the decision. The Fourth Circuit affirmed, rejecting an argument the Medicaid Act, 42 U.S.C. 1396b(d)(2)(A), authorizes a disallowance only when the state has recovered from a "provider."

Plaintiff sued defendant seeking a declaratory judgment that defendant was required to comply with the rules laid out in Title XIX of the Social Security Act, section 1396-1396v, where there was a dispute as to what rate plaintiff must pay defendant when defendant provided emergency transportation services to plaintiff's Medicaid enrollees. At issue was whether the definition of emergency services in section 1396(u)-2(b)(2)(B) applied to section 1396(u)-2(b)(2)(D) and whether section 1396(u)-2(b)(2)(D) covered the services provided by defendants to members of plaintiff's Medicaid program. The court held that the definition of emergency services found in 1396(u)-2(b)(2)(B) applied to section 1396(u)-2(b)(2)(D) where applying different definitions to a single term of art within this one statute would be both cumbersome and illogical. The court also held that the district court erred in granting summary judgment to defendant where the plain meaning of the word outpatient and the structure of the statute supported a finding in favor of plaintiff.