Opinion
3:23cv24700/TKW/ZCB
04-29-2024
DANIEL WOODS, Plaintiff, v. SECRETARY OF HEALTH AND HUMAN SERVICES, et al., Defendants.
REPORT AND RECOMMENDATION
Zachary C. Bolitho United States Magistrate Judge
Plaintiff, proceeding pro se, seeks judicial review of the Medicare Appeals Council's decision denying his claim for payment of a shoe lift. (Doc. 6). Defendant, Secretary of Health and Human Services, has moved to dismiss. (Doc. 12). Plaintiff has responded in opposition (Doc. 14), and Defendant has replied (Doc. 16). For the reasons below, Defendant's motion should be granted.
I. Factual and Procedural Background
At the motion to dismiss stage, the Court assumes the factual “allegations in the complaint are true (even if doubtful in fact).” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 557 (2007).
In his amended complaint, Plaintiff alleges that his right leg is shorter than his left leg. (Doc. 6 at 6). As a result, Plaintiff has received Social Security disability benefits since age seventeen. (Id. at 7). Plaintiff alleges that he has undergone several surgeries because of this issue. (Id.). And Plaintiff says he has suffered from back pain, for which his doctor prescribed a “shoe lift.” (Id.).
Until 2020, Humana Insurance-a Medicare Advantage insurance plan-had paid for Plaintiff's shoe lift. In 2020, however, Plaintiff's Medicare Advantage insurance plan changed to one managed by United Health Care. (Id.). Coverage for his shoe lift was thereafter denied. (Id.). Because coverage was denied, Plaintiff had to pay out of pocket for the shoe lift. (Id. at 9).
Plaintiff appealed the coverage denial to the Medicare Independent Review Entity (IRE). (Doc. 6-1 at 5). The IRE rejected the appeal and upheld the denial of Plaintiff's claim. (Id.). Plaintiff then requested a hearing before an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals. (Id.). That hearing was held on June 15, 2023, after which the ALJ found coverage had been properly denied. (Id. at 7). Plaintiff appealed the ALJ's decision to the Medicare Appeals Council. (Doc. 6-1 at 12). The Medicare Appeals Council affirmed the ALJ's decision on October 30, 2023. (Id. at 12-14). Next, Plaintiff filed the current action seeking judicial review of the Medicare Appeals Council's decision, which stands as the final decision of Defendant Secretary of Health and Human Services. Plaintiff alleges that because of the denial of his claim, he has paid $306.25 out of pocket for the shoe lift. (Doc. 6 at 8). He seeks reimbursement of that amount. (Id.). He also seeks an order requiring Medicare to “cover foot orthotics.” (Id.).
II. Discussion
Defendant has moved to dismiss based on lack of subject matter jurisdiction. See Fed.R.Civ.P. 12(b)(1). Federal courts are courts of limited jurisdiction. Bishop v. Reno, 210 F.3d 1295, 1298 (11th Cir. 2000). If a federal court “determines at any time that it lacks subject-matter jurisdiction, the court must dismiss the action.” Fed.R.Civ.P. 12(h)(3). Generally, there are two categories of federal subject matter jurisdiction: (1) federal question jurisdiction (28 U.S.C. § 1331); and (2) diversity jurisdiction (28 U.S.C. § 1332). Baltin v. Alaron Trading Corp., 128 F.3d 1466, 1469 (11th Cir. 1997). The party asserting federal jurisdiction has the burden of showing that the case falls into one of the two categories. Loren v. Sasser, 309 F.3d 1296, 1304 (11th Cir. 2002) (per curiam).
In this case, Plaintiff's amended complaint says this case falls within the first category-federal question jurisdiction under 28 U.S.C. § 1331. (Doc. 6 at 1). Federal question jurisdiction exists “only when a federal question is presented on the face of” the well-pleaded complaint, such as when federal law creates the cause of action that the plaintiff says entitles him to relief. Caterpillar, Inc. v. Williams, 482 U.S. 386, 392 (1987). The federal law giving rise to the cause of action in this case is 42 U.S.C. § 1395w-22(g)(5).
Under that statute, a Medicare enrollee who has been denied coverage for a “health service” may seek judicial review of the Secretary's decision denying coverage “[i]f the amount in controversy is $1,000 or more.” 42 U.S.C. § 1395w-22(g)(5). Thus, “judicial review is not available for a claim with an amount in controversy less than $1,000.” Acquisto v. Secure Horizons, 504 Fed.Appx. 855, 856 (11th Cir. 2013); see also Global Rescue Jets, LLC v. Kaiser Found. Health Plan, Inc., 30 F.4th 905,911 (9th Cir. 2022) (explaining that a Medicare beneficiary may seek judicial review of a coverage decision “only if the remaining amount in controversy is $1,000 or more (adjusted for inflation)”). So, if a plaintiff seeks judicial review of a Medicare coverage denial that involves less than the jurisdictional threshold, then dismissal is required for lack of subject matter jurisdiction. See Acquisto, 504 Fed.Appx. at 856 (affirming dismissal for lack of subject matter jurisdiction where the plaintiff seeking to challenge a Medicare coverage denial failed to establish that the amount in controversy exceeded $1,000).
This jurisdictional amount is subject to adjustment for inflation. 42 U.S.C. § 1395ff(b)(1)(E)(i); 42 U.S.C. § 1395w-22(g)(5). The applicable adjusted jurisdictional amount in this case appears to be $1,850, as that is the threshold the Medicare Appeals Council included in their Notice of Decision to Plaintiff. (See Doc. 6-1 at 10).
In this case, Defendant argues that subject matter jurisdiction is lacking because Plaintiff seeks $306.25 (the cost he paid for the shoe lift), which is less than the inflation-adjusted amount in controversy requirement of $1,850. Plaintiff has attempted to avoid that conclusion by arguing that he will need a shoe lift for the rest of his life, and “the cost will go up over time.” (Doc. 14 at 2). That argument lacks merit because the Court is being asked to review a particular claim that was denied on a particular date and exhausted through the agency appeal process. And Plaintiff has admitted that the value of that claim is $306.25. The fact that in the future Plaintiff may have additional claims that may be denied and those additional claims may involve a higher dollar amount is irrelevant to the question of whether the Court has jurisdiction over the claim before it today. See generally Odell v. U.S. Dep't of Health & Human Servs., 995 F.3d 718, 723 (9th Cir. 2021) (recognizing that the potential for future claims cannot provide the court with jurisdiction over a case involving current claims). Because what is before the Court today is a challenge to Defendant's denial of a claim valued at $306.25, the Court lacks subject matter jurisdiction because the amount in controversy requirement in 42 U.S.C. § 1395w-22(g)(5) has not been met. Thus, dismissal is required.
To the extent Defendant argues he has also asserted a discrimination claim (Doc. 14 at 2), such a claim should be dismissed (as Defendant asserts) for failure to state a claim upon which relief can be granted under Rule 12(b)(6). (See Doc. 12 at 7-8 n. 3). To survive dismissal for failure to state a claim, “[a] plaintiff must plausibly allege all the elements of the claim for relief. Conclusory allegations and legal conclusions are not sufficient; the plaintiff[] must state a claim to relief that is plausible on its face.” Pedro v. Equifax, Inc., 868 F.3d 1275, 1279 (11th Cir. 2017) (cleaned up). “A claim has facial plausibility when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged.” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009). The pleadings of pro se litigants are to be liberally construed. Boxer X v. Harris, 437 F.3d 1107, 1110 (11th Cir. 2006). “Despite the leniency afforded pro se plaintiffs, the district court does not have license to rewrite a deficient pleading.” Osahar v. U.S. Postal Serv., 297 Fed.Appx. 863, 864 (11th Cir. 2008).
Plaintiff's amended complaint does not state a discrimination claim under the Affordable Care Act, the Americans with Disabilities Act (ADA), or the Rehabilitation Act. To state a discrimination claim under Section 1557 of the Affordable Care Act, a plaintiff must plausibly allege he “(1) was a member of a protected class, (2) qualified for the benefit or program at issue, (3) suffered an adverse action, and (4) the adverse action gave rise to an inference of discrimination.” Griffin v. Gen. Elec. Co., 752 Fed.Appx. 947, 949 (11th Cir. 2019). To state an ADA claim, a plaintiff must plausibly allege: “(1) that he is a qualified individual with a disability; (2) that he was excluded from participation in or . . . denied the benefits of the services, programs, or activities of a public entity or otherwise discriminated against by such entity; (3) by reason of disability.” Shotz v. Cates, 256 F.3d 1077, 1079 (11th Cir. 2001) (cleaned up). The same standard applies to claims under § 504 of the Rehabilitation Act. Allmond v. Akal Sec., Inc., 558 F.3d 1312, 1316 n.3 (11th Cir. 2009).
As the Court previously informed Plaintiff when reviewing his initial complaint, he has failed to include sufficient factual detail to state a plausible claim under the Affordable Care Act, the ADA, or the Rehabilitation Act. Plaintiff has not plausibly alleged that he is qualified for the benefit or program at issue, or that the adverse action at issue has given rise to an inference of discrimination. Instead, with regard to the issue of discrimination, Plaintiff's amended complaint simply says: “my rights in Section 1557 discrimination on the basis of disability.” (Doc. 6 at 8). Such conclusory statements are insufficient to state a disability discrimination claim. See Andrews v. City of Hartford, 700 Fed.Appx. 924, 927 (11th Cir. 2017) (affirming dismissal because the plaintiff made “only the conclusory statement that he was fired because of his disability, which was not sufficient to state a discrimination claim”). Accordingly, Defendant's motion to dismiss should be granted.
The Court previously determined that the proper Defendant in this matter was the Secretary of Health and Human Services and, therefore, service on the other named Defendants was unnecessary. (See Doc. 7). Thus, Plaintiff's case should be dismissed as to the Defendants named in the amended complaint (Doc. 6) even though those Defendants have not appeared in this case.
III. Conclusion
For the reasons above, it is respectfully RECOMMENDED that:
1. Defendant's motion to dismiss (Doc. 12) be GRANTED; and 2. The Clerk of Court be directed to enter judgment in accordance with this Order and close the case.