Justia U.S. 11th Circuit Court of Appeals Opinion Summaries

A former railroad employee, Demetris Hill, was convicted of theft of government property and making a false claim to the Railroad Retirement Board (RRB). Hill had been receiving monthly disability benefits from the RRB since 2012, based on his claim that he was unable to perform substantial gainful activity. As a condition of receiving these benefits, Hill was required to report any changes in his employment status, including any ownership in a family business. Despite this, Hill helped his ex-wife start a janitorial business, SparClean Premier Cleaning Solutions, and failed to report his involvement to the RRB.Hill was initially charged in a 60-count indictment for theft of government money or property. A superseding indictment later charged him with one count of theft of government property, one count of making false claims to the government, and one count of wire fraud. After a jury trial, Hill was found guilty of theft of government property and making false claims but was acquitted of wire fraud. The district court denied Hill’s motion for judgment of acquittal and sentenced him to 33 months for each conviction, to be served concurrently, followed by supervised release. Hill appealed his convictions.The United States Court of Appeals for the Eleventh Circuit reviewed Hill’s appeal. The court found sufficient evidence that Hill was not entitled to the disability payments because he engaged in substantial gainful activity and failed to report his involvement with SparClean. The court also found that Hill knowingly deprived the government of its property by continuing to receive the payments without reporting his employment status. Additionally, the court held that receiving direct deposits while failing to disclose his employment constituted making a false claim to the government. Hill’s arguments regarding the sufficiency of evidence, the jury instruction, and the constitutionality of the False Claims Act were rejected. The Eleventh Circuit affirmed Hill’s convictions. View "USA v. Hill" on Justia Law

The case involves Bradley Rodriguez, who applied for disability benefits and supplemental security income, claiming a disability due to a traumatic brain injury, bipolar disorder, and depression. His application was denied by an Administrative Law Judge (ALJ) with the Social Security Administration (SSA). The Appeals Council also denied his request for review. Rodriguez then filed a federal lawsuit challenging the denial of benefits, raising several constitutional issues regarding the appointment of SSA ALJs, Appeals Council members, and the Commissioner of the SSA. He also argued that the ALJ’s decision was not supported by substantial evidence.The United States District Court for the Southern District of Florida granted summary judgment in favor of the Commissioner of the SSA. The court found that the ALJ was properly appointed, the Appeals Council members were not principal officers requiring presidential appointment and Senate confirmation, and the for-cause removal provision for the Commissioner was unconstitutional but severable. The court also held that Rodriguez was not entitled to a new hearing because he did not show that the unconstitutional removal provision caused him any harm. Additionally, the court determined that the ALJ’s decision was supported by substantial evidence.The United States Court of Appeals for the Eleventh Circuit reviewed the case and affirmed the district court’s decision. The court held that the Commissioner had the statutory authority to appoint SSA ALJs and properly exercised that authority through ratification in July 2018. The Appeals Council members were deemed inferior officers, not principal officers, and thus did not require presidential appointment and Senate confirmation. The court also agreed that the for-cause removal provision for the Commissioner was unconstitutional but severable, and Rodriguez did not demonstrate entitlement to retrospective relief. Finally, the court found that the ALJ’s decision was supported by substantial evidence, including medical records and vocational expert testimony. View "Rodriguez v. Social Security Administration" 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 a claimant, Isaac Flowers, who applied for Social Security Disability benefits due to various health issues including back, neck, shoulder, and joint problems, obesity, vision loss in one eye, and depression and opioid dependence. The Administrative Law Judge (ALJ) initially denied his claim, deeming that he could perform "sedentary work". Later, Flowers applied for benefits again, and the ALJ denied his claim again, this time finding that he could perform "light work", a classification slightly more intensive than "sedentary work".Flowers appealed this decision, arguing that the ALJ's finding that he could perform "light work" wasn't supported by substantial evidence as there was no proof of his condition improving. He also suggested that the ALJ should have considered the previous finding of him only being able to perform "sedentary work".The United States Court of Appeals for the Eleventh Circuit rejected Flowers' argument. Firstly, the court found that Flowers hadn't raised this legal issue in the lower courts and they declined to consider it for the first time on appeal. Secondly, the court concluded that even if Flowers had raised the issue in the lower courts, any error would have been harmless because Flowers hadn't shown that he would be entitled to disability benefits even if he was limited to "sedentary work". Lastly, the court found that the ALJ's decision was supported by substantial evidence. Consequently, the court affirmed the ALJ's decision. View "Flowers v. Commissioner, Social Security Administration" on Justia Law

Plaintiff appealed the district court’s affirmance of the Social Security Administration’s (SSA) denial of his claim for disability insurance benefits (DIB) and supplemental security income (SSI) following the Appeals Council’s remand. He argued that the Administrative Law Judge (ALJ) erred on remand by reconsidering a prior finding of Plaintiff’s residual functional capacity (RFC) after the prior decision had been vacated, in violation of the law-of-the-case doctrine and the mandate rule.   The Eleventh Circuit affirmed. The court explained that the mandate rule, which is “a specific application” of the law-of-the-case doctrine, binds a lower court to execute the mandate of the higher court without further examination or variance. The court wrote that even assuming the law-of-the-case doctrine and mandate rule apply, the ALJ was free to reconsider Plaintiff’s RFC because the 2018 Decision was vacated. The court reasoned that the district court order made no findings about how the ALJ erred in his determination on Plaintiff’s disability. Instead, the district court remanded the case on a motion from the Commissioner without making specific factual findings, including whether or not the ALJ properly determined Plaintiff’s RFC. As a result, the Appeals Council had no factual findings in the remand order from which it could deviate. Additionally, the Appeals Council explained that Plaintiff filed a new SSI claim in 2019, and it consolidated that claim with his initial claims, which stemmed from the same disabilities. The SSA regulations allow an ALJ to consider any issues relating to the claim, whether or not they were raised in earlier administrative proceedings. View "George Weidner, III v. Commissioner of Social Security" on Justia Law

MSPA Claims 1 LLC—the assignee of a now-defunct Medicare Advantage Organization—sued Tower Hill Prime Insurance Company to recover a reimbursable payment. The district court granted Tower Hill’s motion for summary judgment because it determined that MSPA Claims 1’s suit was untimely.The Eleventh Circuit affirmed. The court explained that because it is at least “plausible” that the term “accrues” in Section 1658(a) incorporates an occurrence rule—in fact, and setting presumptions aside, the court wrote that it thinks that’s the best interpretation—that is how the court interprets it. Therefore, MSPA Claims 1’s cause of action accrued in 2012 when MSPA Claims 1’s assignor, Florida Healthcare, paid D.L.’s medical bills and became entitled to reimbursement through the Medicare Secondary Payer Act. Because that was more than four years before MSPA Claims 1 filed suit in 2018, its suit is not timely under 28 U.S.C. Section 1658(a). View "MSPA Claims 1, LLC. v. Tower Hill Prime Insurance Co." on Justia Law

Plaintiff applied for disability benefits, alleging that, as of August 2016, she was unable to work because of degenerative disc disease, bulging and herniated discs, other spine issues, fatigue, migraines, asthma, fatty liver, and food allergies. The district court affirmed the decision of the administrative law judge denying Plaintiff's claims. The district court determined that section 404.1520c, and not the treating-physician rule, applied to Plaintiff’s claim. Plaintiff argued that the court's earlier precedents establishing and applying the treating-physician rule are still good law, notwithstanding the promulgation of section 404.1520c.   The Eleventh Circuit affirmed, finding that the new regulation validly abrogated the treating-physician rule and applied to Plaintiff’s claim. The court found that the new regulation instructs administrative law judges to give a treating physician’s opinion no deference and instead to weigh medical opinions based on their persuasiveness. The Social Security Act (“Act”) conferred “exceptionally broad authority” to the Commissioner “to prescribe standards for applying certain sections of the . . . Act.” The court explained that it has never held that the treating-physician rule is unambiguously required by the Act.   Here, Plaintiff filed her disability claim on April 28, 2017, after the effective date for section 404.1520c. And because section 404.1520 forbids administrative law judges from “defer[ring] or giv[ing] any specific evidentiary weight, including controlling weight, to any medical opinion(s),” 20 C.F.R. Section 404.1520c(a), the administrative law judge did not err by declining to give more weight to the medical opinions of Plaintiff’s treating physicians. View "Zinta Harner v. Social Security Administration, Commissioner" on Justia Law

Plaintiff’s doctors prescribed him Optune, a medical technology that had recently received FDA approval for treating recurrent GBM. The device delivers tumor treating field therapy (TTFT) to inhibit cancer-cell replication. A company called Novocure is the sole supplier of the Optune device, which is rented by patients on a monthly basis.   Because Plaintiff is a Medicare Part B beneficiary, he and Novocure asked Medicare to cover his TTFT. Novocure was held liable for the claims. Plaintiff and Novocure submitted 13 claims to Medicare, corresponding to 13 months of TTFT. The district court held that Plaintiff lacked standing because he hadn’t suffered an injury in fact.   The Eleventh Circuit was tasked with deciding whether Plaintiff has standing to challenge a denial of Medicare coverage where the costs of his treatment were imposed not on him, but rather on a third-party supplier. The court affirmed the district court’s determination that Plaintiff hadn’t suffered an injury in fact.   Here, Plaintiff’s alleged harm will only come to pass due to the challenged action if, at some indefinite point in the future: (1) his condition worsens, (2) he has paid his premiums and stayed on Medicare Part B, (3) he elects to resume TTFT, (4) his doctor prescribes the therapy (5) Plaintiff receives the treatment, (6) he files a claim, (7) which is denied at every level of the Medicare appeals process, (8) the adjudicators determine that Plaintiff’s hypothetical future case presents a “comparable situation,” and (9) they further find that the instant coverage denial and no other source put Plaintiff on notice that he could be held liable. View "Edwin R. Banks v. Secretary, Department of Health and Human Services" on Justia Law

In 2008, following a diagnosis of multiple sclerosis (MS), Karantsalis sued the city under the Americans with Disabilities Act (ADA) and the Rehabilitation Act of 1973 by failing to make its facilities and infrastructure accessible to individuals with disabilities. He later voluntarily dismissed the lawsuit, believing that he lacked constitutional standing because his symptoms were mild and did not prevent him from accessing and using the city’s programs or services. By 2019, Karantsalis’s MS and his symptoms had progressed dramatically: he had started falling, developed a limp, and needed a disabled parking permit. His neurologist had prescribed a wheelchair.He again sued the city under the ADA and Rehabilitation Act alleging the sidewalks, municipal gymnasium, and parking at public facilities were inaccessible. The district court dismissed the case with prejudice, holding that it was barred by the four-year statute of limitations, which was triggered before or during 2008 when Karantsalis became aware of his MS diagnosis. The Eleventh Circuit reversed. From the face of his complaint, Karantsalis’s injury did not occur until at least 2017. Karantsalis could not have sued before he lost his mobility and his ready access to and use of the city’s public services. View "Karantsalis v. City of Miami Springs" on Justia Law

Pupo first applied for supplemental security income (SSI) in June 2011, alleging that she was unable to work due to depression, body tremors, and high blood pressure. Her initial application was denied, but, in 2015, her case was remanded for further proceedings pursuant to sentence four of 42 U.S.C. 405(g). The district court affirmed the subsequent denial of Pupo’s application.The Fifth Circuit reversed and remanded. The decision is not supported by substantial evidence; the ALJ erred by not addressing one of Pupo’s medical diagnoses, her incontinence when assessing her residual functional capacity and the Appeals Council erred by not considering the new medical evidence submitted by Pupo following the ALJ’s denial of her SSI claim. Pupo submitted medical records showing that she had surgery because of her stress urinary incontinence nine days before the ALJ issued his decision. The ALJ did not err in failing to consider Pupo’s borderline age situation because he did not apply the grids mechanically but instead relied on testimony due to Pupo’s non-exertional limitations. View "Pupo v. Commissioner, Social Security Administration" on Justia Law