Justia Public Benefits Opinion Summaries

The City of Huntington and the Cabell County Commission filed lawsuits against AmerisourceBergen Drug Corp., Cardinal Health, Inc., and McKesson Corp., alleging that the defendants contributed to the opioid epidemic by distributing excessive quantities of opioids to pharmacies. The plaintiffs claimed that the defendants' actions created a public nuisance that should be abated under West Virginia common law. The cases were consolidated and remanded to the United States District Court for the Southern District of West Virginia, which held a ten-week bench trial.The district court ruled in favor of the defendants, concluding that the plaintiffs failed to prove that the defendants' conduct was unreasonable or that it proximately caused the opioid epidemic. The court found that the defendants substantially complied with their duties under the Controlled Substances Act (CSA) and that the plaintiffs did not provide sufficient evidence to show that the volume of opioids distributed was excessive or that the defendants failed to maintain effective controls against diversion. The district court also determined that the plaintiffs' proposed abatement plan was not appropriate.The plaintiffs appealed to the United States Court of Appeals for the Fourth Circuit, contesting the district court's factual findings and legal conclusions. The Fourth Circuit certified a question to the Supreme Court of Appeals of West Virginia, asking whether conditions caused by the distribution of a controlled substance can constitute a public nuisance under West Virginia common law and, if so, what the elements of such a claim are.The Supreme Court of Appeals of West Virginia declined to answer the certified question, citing the disputed factual findings and related legal conclusions on appeal. The court emphasized that it could not address the legal issue without a sufficiently precise and undisputed factual record, and any answer would be advisory given the unsettled facts. View "City of Huntington and Cabell County Commission v. AmerisourceBergen Drug Corporation" on Justia Law

Paul Cropper applied for disability insurance benefits and supplemental security income in February 2020, citing various impairments such as anxiety, depression, ADHD, insomnia, and COPD. His application was denied initially and upon reconsideration by the Social Security Administration. Cropper then requested a hearing before an administrative law judge (ALJ), where he presented opinions from his medical providers indicating severe limitations. The ALJ conducted a five-step analysis and denied the application, finding that while Cropper had severe impairments, he could still perform certain jobs available in the national economy. The ALJ found the opinions of Cropper’s primary care provider and psychiatrist unpersuasive.Cropper sought judicial review in the United States District Court for the District of Minnesota, arguing that the ALJ improperly evaluated the evidence, leading to an incorrect residual functional capacity determination. The district court granted summary judgment in favor of the Commissioner, concluding that substantial evidence supported the ALJ’s decision to find the medical opinions unpersuasive.The United States Court of Appeals for the Eighth Circuit reviewed the case de novo and affirmed the district court’s decision. The court held that the ALJ adequately considered the supportability and consistency of the medical opinions as required by the revised regulations. The court emphasized that the ALJ’s findings were supported by substantial evidence, including the conservative course of treatment and the lack of significant outpatient therapy. The court also noted that the ALJ’s reasoning was sufficiently clear to allow for appropriate judicial review. View "Cropper v. Dudek" on Justia Law

Two elderly individuals, Ms. Penelope Lamle and Ms. Maxine Houston, applied for Medicaid but faced delays and additional questions from the Oklahoma Department of Human Services, allegedly directed by attorney Susan Eads. They refused to answer these questions and subsequently sued, seeking an expedited decision, payment of Medicaid benefits, and damages. Both applicants died during the litigation, and their estates were substituted as parties in the appeal.The United States District Court for the Western District of Oklahoma dismissed the action with prejudice, citing the plaintiffs' failure to state a valid claim. However, the court was unaware that the applicants had died while the action was pending.The United States Court of Appeals for the Tenth Circuit reviewed the case. The court found that the claims for an injunction became moot when the agency denied benefits and the applicants died. The court noted that the requested relief would no longer benefit the estates, as the Oklahoma Department of Human Services had already denied the applications. The court also held that the Eleventh Amendment barred the requested retrospective relief. Consequently, the court remanded the case to the district court with instructions to vacate the judgment on the claim for a prospective injunction and dismiss it without prejudice.Regarding the claim against Ms. Eads in her individual capacity, the Tenth Circuit held that she was entitled to qualified immunity. The court found that the plaintiffs did not allege facts showing the violation of a clearly established right. As a result, the court affirmed the dismissal with prejudice of the claim for damages against Ms. Eads. View "Lamle v. Eads" on Justia Law

Jerry L. Blankenship applied for living miner benefits under the Black Lung Benefits Act, claiming he suffered from coal dust-induced pneumoconiosis and was totally disabled. An Administrative Law Judge (ALJ) found Blankenship entitled to a rebuttable presumption of total disability due to pneumoconiosis under 30 U.S.C. § 921(c)(4) and determined that his former employer, Island Creek Coal Company, failed to rebut this presumption. Consequently, Blankenship was awarded benefits. The Benefits Review Board affirmed the ALJ’s decision.Island Creek petitioned for review, arguing that the ALJ improperly conflated the presence of pneumoconiosis and disability causation with the separate total disability analysis. Additionally, Island Creek contended that the ALJ failed to adequately explain his decision to credit the opinions of Blankenship’s medical experts over those of Island Creek’s experts.The United States Court of Appeals for the Fourth Circuit reviewed the case and agreed with Island Creek. The court found that the ALJ improperly relied on the presence of pneumoconiosis and the causation of Blankenship’s impairment in concluding that he was totally disabled. The court also determined that the ALJ failed to provide a sufficient explanation for crediting the medical opinions of Drs. Nader and Green over those of Drs. McSharry and Sargent, violating the duty of explanation under the Administrative Procedure Act.The Fourth Circuit granted Island Creek’s petition for review, vacated the decision of the Benefits Review Board, and remanded the case with instructions for the Board to return Blankenship’s case to the ALJ for reconsideration consistent with the court’s opinion. View "Island Creek Coal Co. v. Blankenship" on Justia Law

K.M., an adult with multiple disabilities, including autism and a seizure disorder, has been receiving Medicaid-funded developmental disabilities services for over twenty years. These services, provided by Washington County Mental Health Services (WCMHS), were supposed to include more than thirty hours of community support each week. However, since March 2020, K.M. has only received two to five hours of support weekly, leading to negative health effects.K.M. petitioned the Human Services Board to order the Department of Disabilities, Aging, and Independent Living (DAIL) to provide the full services he is entitled to. The Board dismissed his petition, stating it failed to specify the action required for compliance and that an order to provide services without available staff was too vague. The Board also interpreted K.M.'s request as seeking a broader policy change, which it deemed outside its authority, citing Husrefovich v. Department of Aging & Independent Living.The Vermont Supreme Court reviewed the case and reversed the Board's dismissal. The Court held that the Board has the statutory authority to order DAIL to provide the services K.M. is entitled to under federal and state law. The Court clarified that while the Board cannot issue broad policy injunctions, it can provide specific relief to individuals. The Court found K.M.'s request for services clear and specific enough to inform DAIL of the required action. The case was remanded to the Board for further proceedings consistent with this opinion. View "In re Appeal of K.M." on Justia Law

The case involves a challenge to two Montana laws, HB 544 and HB 862, and a rule adopted by the Montana Department of Public Health and Human Services (DPHHS) regarding Medicaid funding for abortions. The plaintiffs, including Planned Parenthood of Montana and other healthcare providers, argue that these provisions infringe on the constitutional rights of their patients by imposing restrictions on Medicaid coverage for abortions. Specifically, the laws and rule bar Medicaid from covering abortions provided by non-physicians, require prior authorization for abortion services, and limit Medicaid coverage to abortions deemed "medically necessary" under a restrictive definition.The First Judicial District Court of Lewis and Clark County issued a preliminary injunction to halt the enforcement of HB 544, HB 862, and the DPHHS rule. The court found that the plaintiffs were likely to succeed on the merits of their claims, which included violations of the right to privacy and equal protection under the Montana Constitution. The court applied strict scrutiny, determining that the laws and rule were not narrowly tailored to serve a compelling state interest. The court also found that the plaintiffs would suffer irreparable harm without the injunction and that the balance of equities and public interest favored granting the injunction.The Montana Supreme Court reviewed the case and affirmed the District Court's decision to grant the preliminary injunction. The Supreme Court agreed that the plaintiffs were likely to succeed on the merits, as the challenged provisions infringed on the fundamental right to privacy and equal protection. The court held that the state failed to demonstrate that the laws and rule were narrowly tailored to address a medically acknowledged, bona fide health risk. The Supreme Court also found that the plaintiffs would suffer irreparable harm without the injunction and that the balance of equities and public interest supported maintaining the injunction. View "Planned Parenthood v. State" on Justia Law

M.G. and C.V., medically fragile children under New Mexico’s Medicaid program, sued the New Mexico Human Services Department (HSD) for failing to provide the private duty nursing (PDN) hours they are entitled to. They sought a preliminary injunction to compel HSD to take good faith steps to provide these hours. The district court granted the injunction, and HSD appealed.The United States District Court for the District of New Mexico found that M.G. and C.V. were consistently not receiving their required PDN hours, which placed them at risk of severe medical harm. The court concluded that M.G. and C.V. were likely to succeed on the merits of their Medicaid Act claims, which mandate the provision of PDN services. The court also found that the children would suffer irreparable harm without the injunction, that the balance of harms favored the plaintiffs, and that the injunction was in the public interest. The injunction required HSD to take specific steps, such as negotiating with managed care organizations and increasing monitoring of PDN hour shortfalls, to provide the necessary PDN hours.The United States Court of Appeals for the Tenth Circuit affirmed the district court’s decision. The appellate court held that M.G. and C.V. had standing to seek injunctive relief and that the district court did not err in its conclusions. The court found that the injunction was not impermissibly vague and that the Supreme Court’s decision in Armstrong v. Exceptional Child Center, Inc. did not preclude the issuance of the injunction. The Tenth Circuit concluded that the district court acted within its discretion in granting the preliminary injunction, given the likelihood of success on the merits, the risk of irreparable harm, the balance of harms, and the public interest. View "M.G. v. Armijo" on Justia Law

The case involves a class action lawsuit brought by several minor children, through their legal guardians, against the Commissioner of the Georgia Department of Community Health. The plaintiffs challenged the Department's practices regarding the provision of skilled nursing services under the Medicaid Act. Specifically, they contested the Department's use of a scoresheet to determine the number of skilled nursing hours and the practice of reducing those hours as caregivers learn to perform skilled tasks.The United States District Court for the Northern District of Georgia granted summary judgment in favor of the plaintiffs. The court ruled that the Department's review process did not give appropriate weight to the recommendations of treating physicians and that the practice of reducing skilled nursing hours as caregivers learn skilled tasks violated the Medicaid Act. The district court issued permanent injunctions requiring the Department to approve the skilled nursing hours prescribed by the patients' treating physicians.The United States Court of Appeals for the Eleventh Circuit reviewed the case and reversed the district court's decision. The appellate court held that the Department's review process, which includes the use of a scoresheet to determine a presumptive range of skilled nursing hours, complies with the Medicaid Act. The court also found that the practice of reducing skilled nursing hours as caregivers learn skilled tasks is reasonable and does not violate the Act. The court vacated the permanent injunctions and remanded the case for further proceedings. The appellate court did not address the plaintiffs' challenge regarding the consideration of caregiver capacity, as the district court had ruled that issue moot. The appeal of the preliminary injunctions was deemed moot following the vacatur of the permanent injunctions. View "M.H. v. Commissioner, Georgia Dept. of Community Health" on Justia Law

The case involves Lorain Ann Stiffler, who applied for disability insurance benefits under the Social Security Act, claiming disability due to attention deficit hyperactivity disorder, depression, a mood disorder, right knee problems, and a processing disorder. Her application was initially denied and denied again upon reconsideration. Dr. Khosh-Chashm, who diagnosed Stiffler with major depressive disorder, concluded that she had extreme mental functioning limitations and lacked the cognitive and communicative skills required for gainful employment. However, state agency medical consultants Dr. Goldberg and Dr. Bilik disagreed, concluding that Stiffler was not disabled but had moderate limitations on her ability to carry out detailed instructions, maintain concentration, work with others, make simple work-related decisions, and complete a normal workday and workweek.The Administrative Law Judge (ALJ) affirmed the denial of Stiffler's application for disability benefits. The ALJ rejected Dr. Khosh-Chashm's opinion, finding it unsupported by and inconsistent with the medical evidence and Stiffler's significant daily activities. The ALJ also found no conflict between the testimony of the vocational expert and the Dictionary of Occupational Titles (DOT), concluding that Stiffler could work as a marking clerk, mail clerk, or laundry worker.The United States Court of Appeals for the Ninth Circuit affirmed the district court's judgment, which had upheld the ALJ's decision. The court found substantial evidence supporting the ALJ's evaluation of Dr. Khosh-Chashm's medical opinion and concluded that there was no conflict between Stiffler's limitation to "an environment with few workplace changes" and the DOT's Reasoning Level 2. View "STIFFLER V. O'MALLEY" on Justia Law

Adams, born in 1960, smoked about a pack a day starting at age 18 and worked in coal mines at times between 1979-1995, mostly underground using a “cutting machine” in the “dustiest” areas. Adams struggled to breathe after his retirement. Adams’s 1998 application under the Black Lung Benefits Act, 30 U.S.C. 901(b), was denied because he failed to prove that he had pneumoconiosis. In 2008, Adams sought benefits from Wilgar. His treating physician, Dr. Alam, identified the causes of his 2013 death as cardiopulmonary arrest, emphysema, coal worker’s pneumoconiosis, throat cancer, and aspiration pneumonia.A 2019 notice in the case stated “the Court may look to the preamble to the revised” regulations in weighing conflicting medical opinions. Wilgar unsuccessfully requested discovery concerning the preamble and the scientific studies that supported its conclusions. The ALJ awarded benefits, finding that Adams had “legal pneumoconiosis” and giving Dr. Alam’s opinion that Adam’s coal mine work had substantially aggravated his disease “controlling weight.” All things being equal, a treating physician’s opinion is “entitled to more weight,” 30 C.F.R. 718.104(d)(1). Wilgar's three experts had opined that Adams’s smoking exclusively caused his disease The ALJ gave “little weight” to these opinions, believing that they conflicted with the preamble to the 2001 regulation.The Benefits Review Board and Sixth Circuit affirmed. The preamble interpreted the then-existing scientific studies to establish that coal mine work can cause obstructive diseases, either alone or in combination with smoking. The ALJ simply found the preamble more persuasive than the experts. View "Wilgar Land Co. v. Director, Office of Workers’ Compensation Programs" on Justia Law