Justia Government & Administrative Law Opinion Summaries

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 Smith appealed, arguing her equitable claims were justiciable because the 2017 ruling had not been fully rescinded.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

Petitioner F.E.D., seventy-three years old, was convicted of three counts of first-degree murder and would not be eligible for parole until 2040. In February 2021, the Managing Physician of the New Jersey Department of Corrections submitted to the Commissioner of Corrections a Request for Compassionate Release on behalf of F.E.D. Based on the diagnoses provided by the attesting physicians, the Managing Physician found that F.E.D. “meets the medical conditions established” by N.J.S.A. 30:4-123.51e. Pursuant to N.J.S.A. 30:4-123.51e(d)(1), the Commissioner issued a Certificate of Eligibility for Compassionate Release. A trial court held an evidentiary hearing on the motion. With regard to whether F.E.D. suffered from a “permanent physical incapacity” as defined in N.J.S.A. 30:4-123.51e(1), the trial court relied on the list of “activities of daily living” enumerated in the administration of New Jersey’s Medicaid program, which the court identified to be bathing, dressing, toileting, locomotion, transfers, eating and bed mobility. Applying that standard to the medical diagnoses presented in F.E.D.’s petition for compassionate release, the trial court observed that the attesting physicians had found a diminished ability in instrumental activities of daily living but not an inability to perform activities of basic daily living. The court accordingly found that F.E.D. had not presented clear and convincing evidence that he suffered from a “permanent physical incapacity” within the meaning of N.J.S.A. 30:4-123.51e(d)(1). The Appellate Division found that the Certificate of Eligibility for compassionate release that the Department issued to F.E.D. was invalid based on its view that the Compassionate Release Statute applied only to inmates whose medical conditions rendered them unable to perform any of the activities of basic daily living, and to be inapplicable to any inmate who could conduct one or more of those activities. The New Jersey Supreme Court found that the Compassionate Release Statute did not require that an inmate prove that he is unable to perform any activity of basic daily living in order to establish a “permanent physical incapacity” under N.J.S.A. 30:4-123.51e(l). Rather, the statute required clear and convincing evidence that the inmate’s condition rendered him permanently unable to perform two or more activities of basic daily living, necessitating twenty-four-hour care. Assessing F.E.D.’s proofs in accordance with the statutory standard, the Supreme Court found he did not present clear and convincing evidence that his medical condition gave rise to a permanent physical incapacity under N.J.S.A. 30:4-123.51e(f)(1). View "New Jersey v. F.E.D." on Justia Law

In this case arising out of a child welfare investigation, the Seventh Circuit vacated the judgment of the district court entering summary judgment in favor of Indiana Department of Child Services (DCS) case workers on the grounds of qualified immunity, holding that the facts were too disputed to allow the Court to reach any legal conclusions with confidence.When DCS learned from a social worker that Plaintiffs may not have been providing their infant daughter prescribed medication to control epileptic seizures DCS case workers took the child to the hospital for a blood draw to clarify whether that was so. The results showed that the infant had started the prescription a few days earlier. Plaintiffs filed a complaint under 42 U.S.C. 1983, alleging that the investigation and demand for a blood test violated their constitutional rights as parents under the Fourteenth Amendment and their daughter's rights under the Fourth Amendment. The district court entered summary judgment for the DCS defendants on the grounds of qualified immunity. The Seventh Circuit vacated the summary judgment and remanded the case, holding that the facts were so contested as to limit what the Court could do on appeal. View "Jerger v. Blaize" on Justia Law

A man appealed superior court orders authorizing his commitment for mental health treatment and the involuntary administration of psychotropic medication, arguing the superior court relied on erroneous facts to find that he was gravely disabled and that the court did not adequately consider the constitutional standards established in Myers v. Alaska Psychiatric Institute before authorizing medication. Because the evidence supported the court’s finding that the man was gravely disabled, the Alaska Supreme Court affirmed the commitment order. But the Supreme Court vacated the medication order because the court’s analysis of the Myers factors was not sufficient. View "In the Matter of the Necessity for the Hospitalization of: Jonas H." on Justia Law

In this case involving licenses to operate a retail marijuana dispensary the Supreme Judicial Court affirmed in part and reversed in part the judgment of the Land Court judge ordering the issuance of a special permit to Plaintiff and the issuance of a second injunction, holding that the second injunction exceeded the permissible scope of the judge's authority.After denying Plaintiff's application for a special permit license to operate a recreational marijuana establishment in the City of Taunton the City granted a special permit to a different applicant. Plaintiff filed a complaint challenging the denial of its special permit application. The Land Court judge found the City's denial of Plaintiff's special permit application was arbitrary and capricious and enjoined the City from conducting previously-scheduled licensing proceedings to consider applications from nonparties seeking licenses to operate medical marijuana dispensaries and from issuing any of the four licenses to the pending applicants. A single justice vacated the preliminary injunction. The Supreme Judicial Court vacated the portion of the judgment concerning the city council's licensing hearings and otherwise affirmed, holding that the injunction exceeded the scope of the judge's authority but that the judge did not err in determining that the City's denial was arbitrary and legally untenable. View "Bask, Inc. v. Municipal Council of Taunton" on Justia Law

Illinois moved its Medicaid program from a fee‐for‐service model, where a state agency pays providers’ medical bills, to one dominated by managed care, where private insurers pay medical bills. Most patients of Saint Anthony Hospital are covered by Medicaid, so Saint Anthony depends on Medicaid payments. Over the last four years, it has lost roughly 98% of its cash reserves, allegedly because managed‐care organizations have repeatedly and systematically delayed and reduced Medicaid payments to it. Saint Anthony sued, arguing that Illinois officials owe it a duty under the Medicaid Act to remedy the late and short payments.The Seventh Circuit reversed the dismissal of the suit, concluding that Saint Anthony has alleged a viable claim for relief under 42 U.S.C. 1396u‐ 2(f) and may seek injunctive relief under 42 U.S.C. 1983 against the state official who administers the Medicaid program in Illinois. Illinois has tools available to remedy systemic slow payment problems—problems alleged to be so serious that they threaten the viability of a major hospital and even of the managed‐care Medicaid program as administered in Illinois. If Saint Anthony can prove its claims, the chief state official could be ordered to use some of those tools to remedy systemic problems that threaten this literally vital health care program. View "Saint Anthony Hospital v. Eagleson" on Justia Law

Genesis Healthcare was a healthcare provider participating in the federal “340B Program,” which was designed to provide drugs to qualified persons at discounted prices. Under the Program, the Secretary of the Department of Health and Human Services (“HHS”) enters into agreements with drug manufacturers to sell drugs at discounted prices to entities such as Genesis Healthcare, which could, in turn, sell the drugs to their patients at discounted prices. After Genesis Healthcare purchased the covered drugs from the manufacturers, it dispensed them to patients through its wholly owned pharmacies or contract pharmacies. After the Health Resources and Services Administration (“HRSA”) conducted an audit of Genesis Healthcare in June 2017 for Program compliance, HRSA removed Genesis Healthcare from the 340B Program. The audit report found, among other things, that Genesis Healthcare dispensed 340B drugs to individuals who were ineligible because they were not “patients” of Genesis Healthcare. HRSA rejected Genesis Healthcare’s challenges; Genesis Healthcare, in turn, filed suit seeking a declaration it did not violate the requirements of the Program, and injunctive relief requiring HRSA to reinstate it into the Program and to retract any notifications that HRSA had provided to manufacturers stating that Genesis Healthcare was ineligible under the Program. In response to the lawsuit, HRSA ultimately: (1) notified Genesis Healthcare by letter that it “ha[d] voided” all audit findings and that Genesis Healthcare “ha[d] no further obligations or responsibilities in regard to the audit” and (2) filed a motion to dismiss Genesis Healthcare’s action as moot based on the letter. The district court granted HRSA’s motion, finding that the action was moot. The Fourth Circuit reversed the district court's finding the case was moot: Genesis Healthcare continued to be governed by a definition of “patient” that, Genesis maintained, was illegal and harmful to it. Therefore, there remained a live controversy between the parties. View "Genesis HealthCare, Inc. v. Becerra" on Justia Law

The Supreme Court reversed the judgment of the trial court permanently enjoining the Texas Department of State Health Services from enforcing a new Texas law that prohibited the processing and manufacturing of smokable hemp products, holding that Plaintiffs were not entitled to relief.In their complaint, Plaintiffs - Texas-based entities that manufacture, process, distribute, and sell hemp products - argued that Tex. Const. art. I, 19 invalidated the challenged law and sought an injunction prohibiting Defendant from enforcing the law. The trial court declared that Tex. Health & Safety Code 443.202(4) violated the Texas Constitution and that 25 Tex. Admin. Code 300.104 was invalid in its entirety and enjoined Defendant from enforcing the statute or the rule. The Supreme Court reversed, holding that Plaintiffs' complaints did not assert the deprivation of an interest substantively protected by the Texas Constitution's due course clause. View "Texas Department of State Health Services v. Crown Distributing LLC" on Justia Law

Zelda Sheppard appealed a superior court’s affirmance of an Industrial Accident Board (“IAB” or “Board”) decision granting Allen Family Foods’ (“Employer”) Petition for Review (“Petition”). The IAB determined that Sheppard’s prescribed narcotic pain medications were no longer compensable. Sheppard sought to dismiss the Petition at the conclusion of Employer’s case-in-chief during the IAB hearing, arguing that the matter should have been considered under the utilization review process. After hearing the case on the merits, the IAB disagreed, holding that Employer no longer needed to compensate Sheppard for her medical expenses after a two-month weaning period from the narcotic pain medications. On appeal, Sheppard argued the IAB erred as a matter of law when it denied Sheppard’s Motion to Dismiss Employer’s Petition because Employer failed to articulate a good faith change in condition or circumstance relating to the causal relationship of Sheppard’s treatment to the work injury. Accordingly, Sheppard argued that the Employer was required to proceed with the utilization review process before seeking termination of her benefits. The Delaware Supreme Court determined the IAB’s decision was supported by substantial evidence, therefore the superior court’s decision was affirmed. View "Sheppard v. Allen Family Foods" on Justia Law

The employer-sponsored group health plan offers all of its participants the same limited coverage for outpatient dialysis. A dialysis provider sued the plan, citing the Medicare Secondary Payer statute, which makes Medicare a “secondary” payer to an individual’s existing insurance plan for certain medical services, including dialysis, when that plan already covers the same services, 42 U.S.C. 1395y(b)(1)(C), (2), (4). To prevent plans from circumventing their primary-payer obligation for end-stage renal disease treatment, a plan may not differentiate in the benefits it provides between individuals having end-stage renal disease and other individuals based on the existence of end-stage renal disease, the need for renal dialysis, “or in any other manner” and may not take into account that an individual is entitled to or eligible for Medicare due to end-stage renal disease. The Sixth Circuit ruled that the limited payments for dialysis treatment had a disparate impact on individuals with end-stage renal disease.The Supreme Court reversed. The plan's coverage terms for outpatient dialysis do not violate section 1395y(b)(1)(C) because those terms apply uniformly to all covered individuals. The statute prohibits a plan from differentiating in benefits between individuals with and without end-stage renal disease; it cannot be read to encompass a disparate-impact theory. The statute simply coordinates payments between group health plans and Medicare without dictating any particular level of dialysis coverage. The plan does not “take into account” whether its participants are entitled to or eligible for Medicare. View "Marietta Memorial Hospital Employee Health Benefit Plan v. DaVita Inc." on Justia Law