RANDALL D. WOLCOTT, MD, PA v. Sebelius
2011 U.S. App. LEXIS 5019
| 5th Cir. | 2011Background
- Wolcott, a Texas wound-care provider, sues in official-capacity Medicare context against Secretary Sebelius and TrailBlazer (Medicare contractor) over Part B claims.
- Wolcott assigns patient claims and appeals denials to itself; ALJ decisions increasingly favored Wolcott but denials were reissued on grounds like lack of medical necessity.
- Wolcott alleges delays in payment after successful appeals, improper rationales for new denials, and prepayment review continuation beyond one year.
- Wolcott brought five mandamus counts (I–V) plus due process and APA claims; district court dismissed all five mandamus counts under Rule 12(b)(1)/(6).
- The Fifth Circuit affirms Counts II–V but reverses and remands Count I for mandamus relief; counts III and V are affirmed as to dismissal.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether § 1361 mandamus jurisdiction applies | Wolcott asserts mandamus jurisdiction over unreviewable procedural issues | Defendants rely on § 405(h) as precluding mandamus for Medicare procedures | § 405(h) does not preclude § 1361 mandamus jurisdiction |
| Whether Counts I–II seek nondiscretionary duty relief and are pled adequately | Wolcott pleads non-discretionary duties to pay and timely process appeals | Defendants argue duties are discretionary or amount is a monetary dispute | Counts I and II pleaded adequate nondiscretionary duties and right to relief under mandamus |
| Whether Counts III–V seek improper relief (declaratory/injunctive) beyond mandamus scope | Counts III and V request future non-enforcement relief | These are declaratory/injunctive challenges to ongoing practices | Counts III and V are not proper mandamus claims; subject-matter jurisdiction lacking; dismissed |
| Whether Count IV mandamus claim regarding prepayment review remains live | Wolcott seeks reversal/removal from prolonged prepayment review | Removal moot as Wolcott has been removed; claims for automatic reversal lack duty and adequate remedy | Portion seeking automatic reversal moot; portion seeking removal moot; remaining mandamus claim dismissed |
| Whether the district court erred in dismissing Counts II, III, IV, and V | District court erred in applying improper standards | Counts not supported under mandamus or lack jurisdiction | Affirmed dismissal of Counts II–IV–V; Count I reversed and remanded |
Key Cases Cited
- Shalala v. Illinois Council on Long Term Care, Inc., 529 U.S. 1 (2000) (monetary benefits review in Social Security context; procedural review considerations)
- Heckler v. Ringer, 466 U.S. 602 (1984) (adequacy of remedy and reviewability of agency actions)
- Salfi v. agreed, 422 U.S. 749 (1975) (finality and timing requirements for judicial review)
- Affiliated Professional Home Health Care Agency v. Shalala, 164 F.3d 282 (5th Cir.1999) (mandamus/Medicare review context; circuit discussion of § 405(h))
- Your Home Visiting Nurse Servs., Inc. v. Shalala, 525 U.S. 449 (1999) (mandamus viability in Medicare procedural challenges)
- Green v. Heckler, 742 F.2d 237 (5th Cir.1984) (adequacy of review remedies when merits are not at issue)
- Ringer, 466 U.S. 602 (1984) (adequacy of alternative remedies in administrative reviews)
- Burnett v. Bowen, 830 F.2d 731 (7th Cir.1987) (mandamus jurisdiction for procedural challenges to benefits)