Arturo Porzecanski v. Alex Azar
943 F.3d 472
| D.C. Cir. | 2019Background
- Porzecanski, diagnosed with rare, life‑threatening systemic capillary leak syndrome (SCLS), has been successfully treated with off‑label intravenous immune globulin (IVIG) since 2009.
- On December 16, 2014 Georgetown billed Medicare Part B $29,860.95 for an IVIG infusion; the Novitas contractor initially denied coverage because its LCD did not list SCLS as an approved IVIG indication.
- Porzecanski exhausted the administrative process for that single claim (redetermination, reconsideration, ALJ, and Council delay), sued in district court, and obtained reversal of the December 16, 2014 denial; the district court ordered HHS to reflect coverage for that treatment but denied broader injunctive/declaratory relief for future claims.
- Porzecanski asked the district court to enjoin HHS and its contractors from denying future IVIG claims for his SCLS; he argues this merely implements the December 16 ruling and prevents repeat denials on the same grounds.
- Novitas later revised its LCD to permit IVIG for SCLS in limited circumstances, but Novitas and other contractors are not bound universally by that LCD; Novitas continued to deny some claims and the LCD revisions did not fully satisfy Porzecanski’s requested prospective relief.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Mootness of appeal after Novitas revised LCD | Case is not moot because Novitas continued denials, LCD is limited and nonbinding on other contractors, and Novitas’ revisions do not provide the full relief sought | Revised LCD makes coverage non‑categorically unavailable and thus moots prospective relief claim | Not moot: appeal remains live because LCD is limited, nonprecedential, and denials persisted |
| Authority to issue prospective injunction precluding denials of future IVIG claims | Injunction only effectuates the December 16, 2014 judgment by precluding denial on the same invalidated grounds (doesn't order immediate payments) | Medicare Act’s channeling (42 U.S.C. §§ 405(g), 405(h), 1395ii) bars courts from adjudicating future benefit claims; Ringer/Illinois Council require presentment/exhaustion for each claim | Denied: prospective relief would effectively establish entitlement to future benefits and circumvent the statutory channeling requirement |
| Whether one properly channeled claim authorizes federal court to resolve other, unpresented claims | A single channeled claim gives the court equitable power to prevent repetitive, identical denials of the same benefit | Presentment is an absolute prerequisite for judicial review of each claim; equitable power cannot be used to decide unpresented claims | Held for defendant: presentment requirement applies to future claims; each must be submitted and exhausted through administrative process |
| Availability of APA / Declaratory Judgment Act as alternative bases for prospective relief | APA or Declaratory Judgment Act permits district court to grant relief despite Medicare administrative scheme | Medicare Act’s jurisdictional prerequisites displace independent APA/DJA authority when those prerequisites are unmet; other cases relied on different statutory bases | APA/DJA do not authorize the requested prospective relief absent satisfaction of Medicare Act presentment/exhaustion rules |
Key Cases Cited
- Heckler v. Ringer, 466 U.S. 602 (Sup. Ct. 1984) (claims for future Medicare benefits must be channeled through administrative process; courts may not predeclare entitlement to future payments)
- Shalala v. Illinois Council on Long Term Care, Inc., 529 U.S. 1 (2000) (Medicare §405(h) channeling is strict but preserves judicial review when administrative process would foreclose review)
- Mathews v. Eldridge, 424 U.S. 319 (1976) (presentment of a claim to the Secretary is a prerequisite to judicial review)
- Califano v. Yamasaki, 442 U.S. 682 (1979) (§405(g) does not eliminate courts’ equitable power, but equitable relief is limited and context‑dependent)
- Am. Hosp. Ass’n v. Azar, 895 F.3d 822 (D.C. Cir. 2018) (discussing incorporation of Title II judicial review bar into Medicare scheme)
- Am. Chiropractic Ass’n v. Leavitt, 431 F.3d 812 (D.C. Cir. 2005) (Illinois Council exception applies when administrative route would practically foreclose judicial review)
- Lion Health Servs., Inc. v. Sebelius, 635 F.3d 693 (5th Cir. 2011) (distinguishable: district court enjoined a regulation under a different Medicare statutory review provision)
- Los Angeles Haven Hospice, Inc. v. Sebelius, 638 F.3d 644 (9th Cir. 2011) (distinguishable: injunction against a regulation was appropriate where statutory prerequisites for judicial review were satisfied)