Justia Public Benefits Opinion Summaries

Waters was born with homocystinuria and diagnosed with that condition at the age of six. Homocystinuria is a genetic attribute that causes metabolic issues that prevent Waters’s liver from metabolizing methionine, an amino acid, that produces L-cysteine, another amino acid. Her physician prescribed HCU coolers–a medical food containing a methionine-free protein formula. Waters ingests HCU coolers orally; she has a fully functioning gastrointestinal tract. Waters sought reimbursement for HCU coolers purchased during 2018-2019, under the prosthetic-device benefit of Medicare Part B, 42 U.S.C. 1395k(a)(2)(I); 1395x(s)(8). The National Coverage Determinations Manual explains that, as part of the prosthetic-device benefit, enteral nutrition is considered reasonable and necessary when a patient “cannot maintain weight and strength commensurate with his” “general condition” because food does not reach the digestive tract and specifies that “[e]nteral therapy may be given by nasogastric [nose], jejunostomy [small intestine], or gastrostomy [stomach] tubes.” The NCD acknowledges “[s]ome patients require supplementation of their daily protein and caloric intake,” but “[n]utritional supplementation is not covered under Medicare Part B.”The Sixth Circuit affirmed several levels of denial of Waters’s claim, acknowledging the difficult circumstances of Waters and her family. An HCU cooler is not a stand-alone prosthetic device based on the plain meaning of prosthetic “device” and because an HCU cooler is a medical food according to the FDA. View "Waters v. Becerra" on Justia Law

Hospitals treating Medicare beneficiaries receive greater reimbursements to the extent that the beneficiaries are also entitled to supplemental security income benefits under Title XVI of the Social Security Act. The Secretary of Health and Human Services understands this population to include only patients receiving cash payments during the month in question. Various hospitals contend that this population also includes patients receiving a subsidy under Medicare Part D and vocational training. The district court disagreed and granted summary judgment to the Department of Health and Human Services (HHS).   The DC Circuit affirmed. The court explained that the hospitals argued that Empire compels their construction of the phrase “entitled to supplementary security income benefits.” The court wrote that this s argument misses key distinctions between the Part A and SSI schemes. First, Part A benefits extend well beyond payment for specific services at specific times. Moreover, the court explained that age or chronic disability makes a person eligible for Part A benefits “without an application or anything more,” and individuals rarely, if ever lose this eligibility over time.   Moreover, the court explained that the hospitals contend that HHS arbitrarily excluded patients whose SSI benefits were withheld under the so-called “cross-program recovery” scheme. The court reasoned that this assertion is mistaken. Next, the court explained that the hospitals contend that HHS unreasonably focused on whether patients receive SSI payments when hospitalized because the payments depend on income and resource levels from earlier months. But “eligibility” for the SSI benefit “for a month” depends on the individual’s income, resources, and other characteristics “in such month.” View "Advocate Christ Medical Center v. Xavier Becerra" on Justia Law

Former employees of Alternatives, a for-profit hospice provider, sued under the False Claims Act, 31 U.S.C. 3729, alleging that Alternatives submitted claims for Medicare reimbursement despite inadequate documentation in the patients’ medical records supporting hospice eligibility, under 42 C.F.R. 418.22(b)(2). For a patient to be eligible for Medicare hospice benefits, and for a hospice provider to be entitled to reimbursement, a patient must be certified as “terminally ill.” The district court granted Alternatives summary judgment based on lack of materiality, finding “no evidence” that Alternatives’ insufficiently documented certifications "were material to the Government’s decision to pay.” The court reasoned that “[t]he Government could see what was or was not submitted” yet never refused any of Alternatives’ claims, despite the inadequacy or missing supporting documentation or where compliance was otherwise lacking.The Third Circuit vacated. When a government contractor submits a claim for payment but fails to disclose a statutory, regulatory, or contractual violation, that claim does not automatically trigger liability. The Act requires that the alleged violation be “material” to the government’s decision to pay. The Supreme Court has identified factors to assist courts in evaluating materiality. In this case, the court based its decision principally on the government’s continued payments after being made aware of its deficient documentation, overlooking factors that could have weighed in favor of materiality— and despite an open dispute over the government’s “actual knowledge.” View "Druding v. Care Alternatives" on Justia Law

Bufkin served in the Air Force from 2005-2006. In 2013, he sought service connection for an acquired psychiatric disorder. VA medical records reflected his visits with a VA psychiatrist, who wrote that he met the criteria for PTSD but did not identify the specific stressor or whether the stressor related to Bufkin’s military service. The VA scheduled an examination with a VA psychiatrist, who opined that his “symptoms do not meet the diagnostic criteria for PTSD.” Bufkin filed a notice of disagreement, arguing that the favorable opinion and the unfavorable opinion were in equipoise, and therefore, VA was legally obligated to grant service connection. Bufkin underwent another VA examination with another examiner, who concluded that his symptoms did not meet the diagnostic criteria for PTSD. The VA continued its denial of service connection. While his appeal was pending, another VA psychiatrist opined that in addition to a severe anxiety disorder, Bufkin “suffers from chronic PTSD.”The Board of Appeals denied service connection, finding that the preponderance of evidence supported a finding that Bufkin does not have PTSD. The Veterans Court and Federal Circuit affirmed. There was no error in the Board’s application of the benefit of the doubt rule, 38 U.S.C. 5107(b): “[w]hen there is an approximate balance of positive and negative evidence” the Secretary “shall give the benefit of the doubt to the claimant.” The Board considered conflicting medical statements but found that the rule did not apply. View "Bufkin v. McDonough" on Justia Law

Cavaciuti served in the Army, 1965-1967. In 2020, the Board of Veterans’ Appeals granted him entitlement to a total disability rating due to individual unemployability (TDIU) and directed the VA to assign him an effective date. The VA nonetheless denied Cavaciuti’s claim, finding that he was capable of gainful employment. Cavaciuti sought a writ of mandamus. After negotiations, the VA informed the Veterans Court that it had granted Cavaciuti entitlement to TDIU with a 2008 effective date. Cavaciuti argued that the case was not moot because the RO had not invalidated its erroneous rating decision and that the VA misused confidential settlement information to render the case moot.The court dismissed Cavaciuti’s petition as moot because the VA had provided him with the relief that he sought. Cavaciuti sought attorney fees and expenses under the Equal Access to Justice Act. The Veterans Court denied the application, finding that Cavaciuti did not satisfy the criterion for prevailing party status because the dismissal order did not award benefits, change the parties’ legal relationship, or otherwise address the merits of Cavaciuti’s writ petition. The Federal Circuit affirmed. There was no judicial change in the parties' legal relationship. The VA implemented the Board’s decision, as Cavaciuti requested, following a settlement rather than based on any court order. The fact that the government’s representations would prevent future changes does not render the dismissal a judicial imprimatur sufficient to make Cavaciuti the prevailing party. View "Cavaciuti v. McDonough" on Justia Law

Appellant applied for Supplemental Security Income based on disability. While her application was pending, the Social Security Administration promulgated rules with new criteria for demonstrating disability and made them applicable to pending claims like Appellant’s. An Administrative Law Judge subsequently found Appellant ineligible for benefits under those updated criteria. Appellant then filed suit in federal district court, and the court overturned the agency’s decision on the ground that application of the new criteria was impermissibly retroactive. The court ordered the agency to reconsider Appellant’s case under the criteria in place when she first filed her claim. The district court rejected all of Appellant’s other challenges to the agency’s decision. Both parties appealed.   The DC Circuit reversed the district court’s decision and remand for further proceedings. The court held that hat application of the new criteria to Appellant’s pending claim was not retroactive, but that the Administrative Law Judge erred in his analysis of evidence from Appellant’s treating physician. The court remanded with instructions to the district court to remand the matter to the Administration to reconsider Appellant’s claim while either according controlling deference to her treating physician’s opinion or offering a substantively reasonable explanation for not doing so. View "Angela Cox v. Kilolo Kijakazi" on Justia Law

Perciavalle, serving in the Army from 1962-1964, injured his knee, which required surgery. The VA awarded Perciavalle a 10 percent disability for medial menisectomy under Diagnostic Code (DC) 5259 for “[c]artilage, semilunar, removal of, symptomatic.” In 1971, Perciavalle underwent another orthopedic examination. The VA did not increase Perciavalle’s disability rating. Perciavalle did not appeal. In 2015, Perciavalle requested a reopening of the 1971 rating decision for clear and unmistakable error (CUE), claiming that he was entitled to two separate disability ratings, one for slight instability of the knee under DC 52571 and another based on the 1971 examination for limitation of motion of flexion and discomfort secondary to arthritis under DC 5003-5260. Perciavalle argued that the 1971 x-ray “clearly show[ed] degenerative changes” as compared to the 1966 examination. The regulations allowed for the combination of two or more disability ratings, but stated that the evaluation of the same disability under various diagnoses is to be avoided.The Veterans Court affirmed the Board of Veterans’ Appeal’s denial of Perciavalle’s claim. The Federal Circuit vacated in part. The Board incorrectly interpreted Perciavalle’s CUE claim. Perciavalle’s CUE claim set forth the relevant facts and regulations. Under a sympathetic reading of that claim, the VA was required to “determine all potential claims raised by the evidence, applying all relevant laws and regulations.” View "Perciavalle v. McDonough" on Justia Law

The Supreme Court reversed the decision of the court of appeal affirming the conclusion of the State Department of Health Care Services that the costs of outreach and education activities aimed at Medicaid-eligible patients were categorically nonreimbursable, holding that the chief administrative law judge's ruling was an abuse of discretion.Health care providers entitled to government reimbursement, including federally qualified health centers (FQHCs), for reasonable costs related to the care of Medicaid beneficiaries are required to offer outreach and education activities to members of underserved communities. The FQHC operator in this case sought reimbursement for the outreach and education costs, but the Department determined that the costs were nonreimbursable. The court of appeal affirmed. The Supreme Court reversed, holding that the Department's determination rested on a misunderstanding of relevant legal principles governing the reimbursement of medical provider costs. View "Family Health Centers of San Diego v. State Dep't of Health Care Services" on Justia Law

Following a 2013 car accident, Michelle Baptist, then 50 years old, began experiencing significant neck and shoulder pain, as well as headaches. She had one, possibly two, aneurysms. She applied for Disability Insurance Benefits and Supplemental Security Income the following year. After reviewing her medical records and conducting a hearing, an administrative law judge concluded that Baptist retained the capacity to perform light work and, therefore, was not disabled.The Seventh Circuit affirmed the decision as supported by substantial evidence. Despite initial complications from an aneurysm clipping procedure, Baptist’s medical records indicate that she made a full recovery and experienced no ongoing aneurysm-related symptoms. Two doctors reviewed Baptist’s 2018 MRI. Neither recorded any concerns nor did they observe any impact the MRI results would have on Baptist’s functional capacity. They noted that Baptist presented with full upper and lower extremity strength, normal reflexes, a normal gait, and “no overt weakness.” View "Baptist v. Kijakazi" on Justia Law

Grounds served in the Army from 1969-1972. He was charged with being AWOL during three periods in 1972 (less than 180 days). To avoid a court-martial. Grounds requested to be discharged “for the good of the service,” citing marital and financial problems and stating, if he were to remain in the Army, he would continue going AWOL. Grounds was discharged “[f]or the good of the [s]ervice” and “[u]nder conditions other than [h]onorable.”In 2013, Grounds applied for veterans' benefits. The VA found his multiple periods of AWOL constituted “willful and persistent misconduct,” rendering him ineligible for benefits under 38 C.F.R. 3.12(d)(4). The Board of Veterans Appeals agreed, concluding his discharge was considered “dishonorable” for VA benefits purposes. The Federal Circuit affirmed the Veterans Court's rejection of an argument that 38 U.S.C. 5303(a) controls and cannot be superseded by 38 C.F.R. 3.12(d)(4). Section 5303(a) provides that a veteran is not eligible for benefits if he was discharged by reason of court-martial on the basis of being AWOL for a continuous period of at least 180 days. Under Federal Circuit precedent, section 5303(a) is not the exclusive test for benefits eligibility; 38 C.F.R. 3.12(d)(4) is consistent with and authorized by statute. While Grounds’ misconduct did not constitute a statutory bar to VA benefits under section 5303. the Board did not clearly err in finding that his multiple periods of AWOL constituted a regulatory bar to benefits. View "Grounds v. McDonough" on Justia Law