Justia Public Benefits Opinion Summaries

Clemons worked as a coal miner for 10 years and smoked two packs per day for 30 years. Clemons suffered and died from COPD. His claims for federal black-lung benefits (30 U.S.C. 901) were denied. An ALJ awarded Mrs. Clemons survivor’s benefits after considering three medical opinions. Dr. Sikder diagnosed Clemons with legal pneumoconiosis in the form of COPD that resulted from both cigarette smoking and from coal-mine dust exposure. Doctros Habre and Broudy attributed Clemons’s COPD solely to his cigarette smoking. The ALJ credited Sikder’s opinion as well-documented, well-reasoned, and supported by substantial evidence, irrespective of the length of coal mine employment she considered, so that opinion was accorded “probative weight” while the other opinions did not sufficiently explain why Clemons’s coal-mine dust exposure did not contribute “at least in part” to his COPD. The Benefits Review Board affirmed, concluding that the evidence was sufficient to establish the presence of legal pneumoconiosis.The Sixth Circuit denied a petition for review, finding that the ALJ took the coal mine employment discrepancy into account when he weighed Dr. Sikder’s opinion, and acted within his discretion in explaining that the discrepancy was not so great as to detract from the opinion’s probative value. View "Huscoal, Inc. v. Director, Office of Workers’ Compensation Programs, United States Department of Labor" on Justia Law

Plaintiff filed for Social Security benefits, but her application was denied by the Social Security Commissioner. The Appeals Council denied review, which made the Commissioner’s decision final. Plaintiff appealed that decision to the district court, which denied her motion and granted the Commissioner’s motion for judgment on the pleadings. Plaintiff appealed that judgment.   The Second Circuit affirmed in part and remanded in part. The court held the district court failed to properly assess Plaintiff’s Residual Functional Capacity (RFC) with regard to her ability to work consistently as well as her limitations regarding social interactions, and that substantial evidence accordingly does not support the determination that Plaintiff’s psychological impairments do not render her disabled. By contrast, the court held that substantial evidence does support the determination that Plaintiff’s physical impairments do not render her disabled. View "Rucker v. Kijakazi" on Justia Law

The Ninth Circuit reversed in part and vacated in part the district court’s grant of Defendants’ motion to dismiss, and remanded for further proceedings, in an action in which federally-qualified health centers operating in Arizona and their membership organization alleged that the Arizona Health Care Cost Containment System, which administers Arizona’s Medicaid program, and its director violated 42 U.S.C. Section 1396a(bb) and binding Ninth Circuit precedent by failing or refusing to reimburse Plaintiffs for the services of dentists, podiatrists, optometrists, and chiropractors.   First, the panel held that the court’s precedent in California Ass’n of Rural Health Clinics v. Douglas (“Douglas”), 738 F.3d 1007 (9th Cir. 2013), established that FQHC services are a mandatory benefit under Section 1396d(a)(2)(C) for which Plaintiffs have a right to reimbursement under Section 1396a(bb) that is enforceable under 42 U.S.C. Section 1983. The panel rejected Defendants’ interpretation of Section 1396d(a)(2)(C)’s phrase “which are otherwise included in the plan” as applying to both the phrases “FQHC services” and “other ambulatory services offered by a [FQHC.]” The panel, therefore, rejected Defendants’ assertion that Section 1396d(a)(2)(C) only required states to cover FQHC services that are included in the state Medicaid plan.   The panel recognized that Douglas held that the mandatory benefit of “FQHC services” under § 1396d(a)(2)(C) includes “services furnished by . . . dentists, podiatrists, optometrists, and chiropractors” as well as doctors of medicine and osteopathy. The panel held that Arizona’s categorical exclusion of adult chiropractic services violated the unambiguous text of the Medicaid Act as interpreted in Douglas. View "AACHC V. AHCCCS" on Justia Law

This dispute is about whether Texas must provide around-the-clock nursing services to a disabled individuals even though the expense of doing so exceeds the cost cap in the state’s Medicaid program. Plaintiff contends that the Americans with Disabilities Act and Rehabilitation Act require this service because the alternative of institutionalization would amount to discrimination. The district court issued a preliminary injunction requiring Texas to provide the nursing services.   The Fifth Circuit vacated the injunction. The court explained that with the scorecard lopsided in favor of exercising jurisdiction, it is unlikely the district court abused its discretion in declining to abstain. Further, although Plaintiff has shown that the district court should hear her claims, we conclude she is unlikely to succeed on one of them: her due process claim. The court found that because it is unlikely that Plaintiff has a property interest in the treatment she is seeking, a preliminary injunction was not warranted on her due process claim. Finally, on the current record, Plaintiff has not shown that she can prevail on an Olmstead claim seeking services that exceed the cost cap in Texas’s Medicaid waiver program. View "Harrison v. Young" on Justia Law

Carter served on active duty in the U.S. Marine Corps from 1979-1980; he was identified as having damaged a government vehicle. According to the military police (MP), Carter became combative during his apprehension and struck an MP. Another MP then struck Carter in the head with his nightstick, resulting in an in-service head injury. Carter has residuals of a traumatic brain injury due to the incident. In 1981, Carter filed a VA claim seeking benefits for his head injury. The regional office denied his claim, Under 38 C.F.R. 3.301(a), service connection may be granted only when a disability was incurred or aggravated in the line of duty “and not the result of the veteran’s own willful misconduct.” The office concluded Carter’s own action “was the proximate cause of his injuries.”The Board of Veterans’ Appeals reopened the matter in 2014. After the regional office completed additional fact-finding on remand, the Board concluded that Carter’s combative behavior during his arrest “represent[ed] deliberate or intentional wrongdoing on the part of [Carter] and reckless disregard of its probable consequences,” and that the MP’s use of force in response “reasonably f[ell] within the realm of ‘probable consequences.'” The Veterans Court and Federal Circuit affirmed. The Board applied the correct legal standard in determining that Carter’s injury was the result of his willful misconduct. View "Carter v. McDonough" on Justia Law

The Mississippi Division of Medicaid (DOM) and Yalobusha County Nursing Home (YNH) disputed four costs submitted for reimbursement by YNH in its fiscal year 2013 Medicaid cost report. The DOM appealed a Chancery Court’s judgment ordering the DOM to reverse the four adjustments at issue. Because the DOM correctly interpreted the appropriate statutes and because its decisions were supported by substantial evidence, the Mississippi Supreme Court reversed the chancery court’s order and rendered judgment reinstating the decisions of the DOM. View "Mississippi Division of Medicaid v. Yalobusha County Nursing Home" on Justia Law

Plaintiff appealed from the district court’s judgment upholding the Social Security Commissioner’s denial of her application for social security disability insurance benefits. She argues that the administrative law judge (ALJ) believed that she lacked the ability to follow detailed instructions, but failed to include that limitation in the hypothetical question posed to the vocational expert or in the residual functional capacity finding. Plaintiff also contends that the ALJ failed to adequately explain why only partial weight was given to the opinions of her treating mental health providers.   The Eighth Circuit affirmed. The court considered the fact that the ALJ had found earlier in the decision that Plaintiff had only a moderate limitation in understanding, remembering, and applying information. The sentence could thus be read as finding the opinion “not necessarily pertinent,” because the ALJ was not giving controlling weight to the providers’ opinion and because Plaintiff’s moderate limitations were accounted for in the hypothetical question and the residual functional capacity determination.Further, the court found to be unpersuasive Plaintiff’s alternative argument that the ALJ failed to adequately explain why she gave only partial weight to the testimony of Plaintiff’s mental health providers- a licensed independent social worker and an advanced registered nurse practitioner. Under the regulations, neither mental health provider is considered an acceptable medical source whose opinion may be afforded controlling weight. Moreover, their opinion was “entitled to relatively little evidentiary value” because it was “rendered on a check-box and fill-in-the-blank form.” Thus, the court concluded that substantial evidence supported the ALJ’s denial of benefits. View "Melissa Galloway v. Kilolo Kijakazi" on Justia Law

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

In 2006, LaBonte went absent without leave (AWOL) from the Army for six months. He voluntarily returned to his base, pleaded guilty to desertion in a court-martial proceeding, and received a Bad Conduct Discharge. In 2012, LaBonte was diagnosed with post-traumatic stress disorder (PTSD), stemming from his combat service in Iraq. In 2014, he was found eligible for VA benefits for service-connected PTSD, traumatic brain injury, depression, headaches, back pain, tinnitus, a painful scar, and ulcers. In 2016, LaBonte received a 100% service-connected disability rating.In 2015, LaBonte applied to the Army Board for Correction of Military Records (ABCMR), seeking retroactive medical retirement. He alleged that, while in the Army, he had permanent disabilities incurred during service that rendered him unfit for service before his absence without leave. In 2020, on remand, ABCMR again denied LaBonte’s claim. The Claims Court dismissed an appeal, finding that, in order for ABCMR to grant LaBonte disability retirement, it would have to correct LaBonte’s DD-214 Form to show that he was separated due to physical disability rather than due to a court-martial conviction and that 10 U.S.C. 1552(f), prohibited such a correction. The Federal Circuit reversed. ABCMR was not required to change LaBonte’s DD-214 in order to grant him disability retirement. The 214 is a record of events, not intended to have any legal effect on the termination of a soldier’s service. View "LaBonte v. United States" on Justia Law

Plaintiffs worked for MBO and Trustmark, which provide medical billing and debt‐collection services to healthcare providers. After they raised concerns about their employers’ business practices, the plaintiffs were fired. They sued MBO, Trustmark, and MBO's client, the University of Chicago Medical Center (UCMC), under the False Claims Act, 31 U.S.C. 3729. Regulations specify that Medicare providers seeking reimbursement for “bad debts” owed by beneficiaries must first make reasonable efforts to collect those debts. The plaintiffs claim that UCMC knowingly avoided an obligation to repay the government after it effectively learned that it had been reimbursed for non-compliant debts; MBO and Trustmark caused the submission of false claims to the government. Each plaintiff also claimed retaliation.The Seventh Circuit affirmed the dismissal of the complaint, in part. The district court properly dismissed the claim against UCMC, which neither had an established duty to repay the government nor acted knowingly in avoiding any such duty. The direct false claim against MBO was also correctly dismissed. The complaint failed to include specific representative examples of non-compliant patient debts, linked to MBO, for which reimbursement was sought. The court reversed in part; the complaint includes specific examples of patient debts involving Trustmark. Two plaintiffs alleged facts that support the inference that they reasonably believed their employers were causing the submission of false claims. View "Sibley v. University of Chicago Medical Center" on Justia Law