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

Plaintiffs, a class of Medicaid beneficiaries who suffered from severe developmental disabilities, sued the NCDHHS, PBH, and the director of PBH, alleging that defendants violated their rights under the Medicaid statute and the Due Process Clause of the Fourteenth Amendment by reducing their health care services without notice and an opportunity for a hearing. On appeal, PBH and the director challenged the district court's entry of a preliminary injunction. However, the NCDHHS did not join the appeal. Given that the NCDHHS had decided not to litigate the appeal, the court concluded that the Medicaid statute, 42 U.S.C. 1396a(a)(5), and accompanying regulations precluded PBH from appealing in the absence of the NCDHHS. Accordingly, the court dismissed the appeal. View "K.C. v. Shipman" on Justia Law

Defendant appealed a district court order adding to her previously imposed sentence a new requirement that she apply all tax refunds and other money she received from any "anticipated or unexpected financial gains" toward an outstanding restitution obligation imposed on her as a part of her sentence. Defendant was convicted of theft of government property because she received Supplementary Security Income (SSI) from the Social Security Administration after her eligibility for such payments had ended. Defendant had been receiving the money on behalf of her special-needs daughter but failed to notify the government when she subsequently married and her husband's income made her ineligible for SSI. The court concluded that the district court abused its discretion by later amending the original sentence in the absence of evidence of the impact the amendment would have on defendant's ability to support herself and her family and, therefore, the court vacated the order. View "United States v. Grant" on Justia Law

Plaintiffs, thirteenth North Carolina residents who lost access to in-home personal care services (PCS) due to a statutory change, brought suit challenging the new PCS program. The district court granted plaintiffs' motions for a preliminary injunction and class certification. Defendants appealed, raising several points of error. The court agreed with the district court's conclusion that a preliminary injunction was appropriate in this case. The court held, however, that the district court's order failed to comply with Federal Rule of Civil Procedure 65 because it lacked specificity and because the district court neglected to address the issue of security. Accordingly, the court remanded the case. View "Pashby v. Delia" on Justia Law

Plaintiff challenged the district court's judgment upholding the decision of the SSA denying his application for disability benefits. The court held that a VA disability determination must be accorded substantial weight in Social Security disability proceedings. The court also held that an ALJ must give retrospective consideration to medical evidence created after a claimant's last insured date when such evidence could be "reflective of a possible earlier and progressive degeneration." After considering all relevant evidence, and upon determining that plaintiff was disabled at any time, an ALJ must consult with a medical advisor if the date of onset of the disability was ambiguous. In this case, the ALJ made two errors of law in conducting his analysis of the evidence concerning whether plaintiff was disabled before his DLI and therefore, the court vacated the district court's judgment. View "Bird v. Commissioner of Soc Sec" on Justia Law

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 appealed the district court's order affirming the Commissioner's denial of her application for supplemental security income (SSI). The court found that substantial evidence supported the ALJ's conclusion that plaintiff was not disabled within the meaning of the Social Security Act, 42 U.S.C. 301 et seq. Accordingly, the court affirmed the district court's grant of judgment on the pleadings in favor of the Commissioner. View "Hancock v. Astrue" on Justia Law

Plaintiff applied for Social Security disability insurance benefits and an ALJ denied the claim, noting that plaintiff failed to provide an opinion from his treating physician. When plaintiff requested review of his claim by the Appeals Council, he submitted a letter from his treating physician detailing the injuries and recommending significant restrictions on plaintiff's activity. The Appeals Council made this letter part of the record but denied plaintiff's request for review. Thus, the ALJ's decision denying benefits became the final decision of the Commissioner of the Social Security Administration. Plaintiff appealed, contending that the Appeals Council erred by failing to articulate specific findings justifying its denial of his request for review. The court rejected the argument and held that the Appeals Council need not explain its reasoning when denying review of an ALJ decision. But because in this case the court could not determine if substantial evidence supported the denial of benefits, the court reversed and remanded.

Plaintiff, an unincorporated association made up of homeless and formerly homeless people that advocated for their rights, sued defendants, alleging that defendants had conspired to establish the Conrad Center on Oliver Hill Way, a site removed from Richmond's downtown community, for the purpose of reducing the presence of the homeless population in the downtown area by providing services for them in a remote location. Plaintiff claimed that the relocation of homeless services to the Conrad Center violated 42 U.S.C. 1983 and 1985(3); the Americans with Disabilities Act (ADA), 42 U.S.C. 12101 et seq.; the Equal Protection Clause of the Fourteenth Amendment; and the Fair Housing Act (FHA), 42 U.S.C. 3601 et seq. The court held that plaintiff did not state a valid section 1985(3) conspiracy claim; plaintiff's 1983 and equal protection claims were barred by the applicable statute of limitations; plaintiff's FHA claims were barred by the two-year statue of limitations and, more fundamentally, they failed to state a claim upon which relief could be granted; and plaintiff's ADA retaliation claim was properly dismissed. Accordingly, the court affirmed the judgment of the district court.

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."