Justia Government & Administrative Law Opinion Summaries

Hall, an aviation mechanic, was discharged in 2001 by the military because of pain from an ankle injury. He was deemed by the Department of Veterans Affairs to be 70 percent disabled and to be “unemployable” in “a substantially gainful occupation” and totally disabled, 38 C.F.R. 4.16. In 2010 he applied for social security disability benefits on the ground that pain from his ankle injury, plus back and knee pain and other ailments, had worsened and rendered him totally disabled under Social Security Act standards. From 2005-2011 he underwent physical examinations and diagnostic tests. Some results were normal but many were not, revealing torn ligaments, obesity, possible arthritis, an “alignment problem” in his back, and fibromyalgia. Hall testified about his pain and inability to perform normal functions. The Seventh Circuit reversed the denial of benefits. Several doctors noted that Hall had been in pain when examined, which was some corroboration of his testimony. The ALJ could have resolved her doubts by ordering an MRI or directing a further examination by a medical expert. In addition, her failure to analyze and weigh the VA determination that Hall is totally disabled was a further oversight. View "Hall v. Colvin" on Justia Law

When the applicant was 15 years old, “Harrington rods” were inserted into his spine to correct a 57-degree curvature of the spine. He then developed chronic back pains. He also has cognitive difficulties. At age 20 he was determined to be eligible for social security disability benefits, but he later obtained a job at a nonprofit organization, driving disabled clients, helping with cooking and cleaning, and performing clerical tasks. The Social Security Administration determined in 1999 (when the applicant was 32) that he was not disabled and tried to recover the $65,000 in benefits. He declared bankruptcy. Three years later, he was fired because he could not keep up with the demands of the job. Two years later he reapplied for social security disability benefits. Several physicians and mental-health professionals diagnosed: chronic back pain; cubital tunnel syndrome; a somatoform disorder; depression, anxiety, panic attacks, agoraphobia, low intelligence, dizziness, migraine headaches, and deficient short-term memory. The applicant and his father testified to sleeplessness, loss of balance, blurred vision, and abdominal pain. The ALJ concluded that he was capable of unskilled light work of a routine and repetitive character and was not disabled. The Seventh Circuit reversed the denial of benefits, finding the opinion “riddled with errors.” View "Adaire v. Colvin" on Justia Law

Lisa Bailey, a fifty-one-year old who was considered morbidly obese, requested, through her physician, Medicaid authorization for gastric bypass surgery. The Montana Department of Public Health and Human Services (Department) denied the request because gastric bypass surgery is a non-covered service under Department administrative rules. A hearing officer upheld the Department’s determination, and the Board of Public Assistance adopted the decision of the hearing officer. The district court affirmed. Bailey appealed, asking that the Department be required to conduct a determination of medical necessity for the procedure. The Supreme Court affirmed, holding that the Department’s rule excluding coverage for all invasive procedures undertaken for the purpose of weight reduction, including gastric bypass surgery, is not unreasonable or contrary to federal law. View "Bailey v. Mont. Dep’t of Pub. Health & Human Servs." on Justia Law

In 1996 Ritzhoff was injured while working as a banquet server. He sustained permanent injuries to his ankle and injured his hand and back. His treating psychiatrist initially evaluated Ritzhoff in 2001 and noted that Ritzhoff demonstrated diminished cognitive functioning, had severe depression, suicidal ideation, severe anxiety, and total neuroticism. The doctor found Ritzhoff temporarily totally disabled on a psychiatric basis and in need of emotional treatment. His employer made temporary disability payments until 2006. Ritzhoff admitted working from time-to-time since his injury. At a third hearing in 2013, Ritzhoff refused to respond to cross-examination. The workers’ compensation judge found Ritzhoff totally permanently disabled on a psychiatric basis, originating in the orthopedic injury. The Workers’ Compensation Appeals Board affirmed. The court of appeal annulled the determination. That the decision was supported by substantial evidence is beside the point. The appeals board exceeded its powers when it adopted a decision as its own that was flawed by a denial of due process with respect to cross-examination. View "Ogden Entm't Servs. v. Workers' Comp. Appeals Bd." on Justia Law

Plaintiffs filed a putative class action suit against the Secretary on behalf of Medicare beneficiaries who were placed into "observation status" by their hospitals rather than being admitted as "inpatients." Placement into "observation status" allegedly caused these beneficiaries to pay thousands of dollars more for their medical care. The district court granted the Secretary's motion to dismiss and plaintiffs appealed. The court affirmed the dismissal of plaintiffs' Medicare Act, 42 U.S.C. 1395, claims where plaintiffs lack standing to challenge the adequacy of the notices they received and nothing in the statute entitles plaintiffs to the process changes they seek. However, the court vacated the district court's dismissal of plaintiffs' Due Process claims where the district court erred in concluding that plaintiffs lacked a property interest in being treated as "inpatients," because the district court accepted as true the Secretary's assertion that a hospital's decision to formally admit a patient is "a complex medical judgment" left to the doctor's discretion. The district court's conclusion constituted impermissible factfinding, which in any event is inconsistent with the complaint's allegations that the decision to admit is guided by fixed and objective criteria. View "Barrows v. Burwell" on Justia Law

Petitioner was admitted to a nursing home in September 2010. She was eighty-seven years old at the time, and had a diagnosis of dementia and Alzheimer's disease. Petitioner's adult daughter, who had the authority to act on petitioner's behalf by virtue of a power of attorney, submitted an application for long-term care Medicaid benefits in January 2011. The application sought coverage for petitioner, retroactive to October 1, 2010, pursuant to a Medicaid rule authorizing benefits for up to three months preceding the month of application. A benefits specialist with the Department for Children and Families testified that, in response to the application, she sent two separate verification requests to petitioner's daughter and an administrator at petitioner's nursing home. The Department received no response to these requests. Accordingly, in March 2011, the Department issued a Notice of Decision ("Notice") denying the application. No appeal of the denial was filed by petitioner or a person acting on her behalf within the ninety-day limit. Petitioner's daughter would submit a total of four applications, each with a request from the Department for additional information, and each time, no information was provided, and the applications were denied. With the assistance of her son, petitioner filed a fifth application for benefits in February 2012. This time, additional information verifying petitioner's financial eligibility was provided, and the application was approved by the Department in May 2012 with benefits retroactive to November 2011, which was three months prior to the date of the fifth and final application. Petitioner appealed that decision, seeking coverage retroactive to October 2010, which would have been three months prior to her first application from January 2011. An evidentiary hearing was held in July 2013 before a Department hearing officer. The Board adopted the hearing officer's findings and issued a decision reversing the Department's decision to limit retroactive benefits to November 2011. The Board concluded that, for reasons of equitable estoppel, petitioner could be awarded benefits retroactive to October 1, 2010 based on the date of the initial application. The Department sought review by the Secretary, who reversed the Board's decision. Because petitioner did not respond to the Department's multiple requests for verification, did not advise the Department of any valid reasons for failing to respond, and informed the Department's benefits specialist that the failure to respond was her responsibility, that she had "dropped the ball." Accordingly, the Secretary found no justification to invoke the doctrine of equitable estoppel, and reversed the Board's decision. Finding no reversible error, the Vermont Supreme Court affirmed the Secretary's reversal of the Board's ruling. View "In re Bernice Landry" on Justia Law

At issue in this case was services that Maine Medical Center provided to Medicare/Medicaid “dual-eligible” patients, that is, patients covered by both Medicare and the state-administered Medicaid insurance program, MaineCare. The Secretary for the Department of Health and Human Services denied Maine Medical’s claim for partial federal reimbursement of “bad debt” for the fiscal years 2002 and 2003. A “bad debt” is an amount considered to be uncollectible for covered services that may be eligible for federal reimbursement under certain conditions. The Secretary denied reimbursement because Maine Medical had not acquired from MaineCare a state-issued remittance advice to use as proof. The district court affirmed. The First Circuit affirmed, holding that it was not arbitrary and capricious for the Secretary (1) to demand that Maine Medical provide documentation from the State confirming the identity of Medicaid-eligible beneficiaries and qualified Medicare beneficiaries, the amount that is the State’s to pay, and the State’s refusal to pay; and (2) to deny Maine Medical’s reimbursement claims that were unsupported by such documentation. View "Me. Med. Ctr. v. Burwell" on Justia Law

Brian Shaffer, who had severe autism and chemical sensitivities, resided with his mother, Delores Shaffer, who was paid to provide private duty nursing (PDN) care to Brian. In 2011, Brian’s Medicaid coverage was transferred to Coventry Health Care of Nebraska, Inc. When Coventry determined that the nursing services were not medically necessary, Shaffer requested a State fair hearing with the Nebraska Department of Health and Human Services. Coventry participated in the administrative proceedings, at which a hearing officer concluded that the PDN services were not medically necessary. Delores sought judicial review of the order, but the petition did not name Coventry as a respondent. The district court reversed the order of the Department, finding the PDN services that Delores provided to Brian were medically necessary. Coventry appealed. The Supreme Court vacated the order of the district court, holding that Coventry was a “party of record” at the State fair hearing and therefore a necessary party in the subsequent appeal to the district court, and the failure to make Coventry a party to the appeal deprived the district court of jurisdiction.View "Shaffer v. Neb. Dep’t of Health & Human Servs." on Justia Law

Duarte joined the California State Teachers’ Retirement System (CalSTRS) in 1993. He earned 2.023 years of service. He took unpaid personal leave for Duarte for the 1995-1996 school year and unpaid educational leave for 1996-1997 and 1997-1998. Duarte worked one season as a forest firefighter, attended law school, and worked as a paralegal. In 2003, Duarte returned to teaching in Oakland. On his second day he was assaulted and threatened by students. Duarte has not returned to teaching. In 2004, Duarte filed a worker’s compensation claim. After four evaluations, he entered into a stipulated settlement that indicated a “serious dispute” regarding the scope of Duarte’s disability. In 2006, Duarte sought social security disability benefits; it was determined that he was disabled from the date of the 2003 incident and became eligible for monthly disability benefits in 2005. Duarte’s student loans were forgiven. In 2008, Duarte sought CalSTRS disability retirement benefits. CalSTRS repeatedly asked Duarte to submit medical records and other documents. An ALJ upheld denial of Duarte’s application because he refused to complete the independent medical evaluation ordered under Education Code 24103 (b),. The trial court and court of appeal affirmed, rejecting an argument that the doctrine of collateral estoppel bars CalSTRS from relitigating his disability because several other state agencies have found him to be disabled.View "Duarte v. CA. State Teachers' Ret. Sys." on Justia Law

This case stemmed from plaintiffs' request for tuition assistance for their daughter under the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. 1400 et seq. Plaintiffs filed suit challenging the State Review Officer's (SRO) decision to deny reimbursement for private schooling and the district court reversed in part and ordered the school district to reimburse plaintiffs for May 1, 2009 to May 31, 2009, and for the 2009-2010 school year. Because the court deferred to the SRO's determination that plaintiffs did not meet their obligation to demonstrate the appropriateness of their daughter's placement, plaintiffs cannot recover under the IDEA for any portion of the time she was placed at Family Foundation. Accordingly, the court reversed the judgment of the district court and remanded for entry of an order affirming the SRO's decision.View "Hardison v. Bd. of Ed. Oneonta City Sch. Dist." on Justia Law