Zhang v. UnitedHealthCare ( 2021 )

1 WO 2 3 4 5 6 IN THE UNITED STATES DISTRICT COURT 7 FOR THE DISTRICT OF ARIZONA 8 9 Rong Zhang, No. CV-20-02064-PHX-GMS 10 Plaintiff, ORDER 11 v. 12 UnitedHealthCare, 13 Defendant. 14 15 16 Before the Court is Defendant Arizona Physicians IPA, Inc.’s (“Defendant”) Motion 17 to Dismiss. (Doc. 5.) For the following reasons, the Motion is granted. 18 BACKGROUND 19 Plaintiff Rong Zhang (“Plaintiff”) is a Medicare Part C enrollee. He thus receives 20 benefits from a Medicare Advantage Organization (“MAO”), rather than directly from the 21 Government. Defendant is a MAO. 22 Plaintiff alleges that he received a root canal treatment in 2015. (Doc. 1-3 at 6.) 23 “However, because of the incomplete and unsuccessful treatment, the infection symptoms 24 reappeared on September 2019.” Id. Plaintiff claims that his “retreatment got denied by 25 UHI” and “was told that [his] plan did cover root canal but not retreatment.” Id. Plaintiff 26 alleges that “[d]ue to the bureaucracy, arrogance and wrongdoing of UnitedHealthCare, 27 [he] ha[s] been suffering a lot both physically and mentally for almost one year, especially 28 in this great pandemic situation.” Id. As a result, Plaintiff seeks compensation for 1 retreatment expenses, court expenses, and physical and mental suffering from Defendant. 2 Id. 3 DISCUSSION 4 I. Legal Standard 5 Federal Rule of Civil Procedure 12(b)(1) allows a party to move to dismiss a 6 complaint for lack of subject matter jurisdiction. “The party asserting jurisdiction has the 7 burden of proving all jurisdictional facts.” Indus. Tectonics, Inc. v. Aero Alloy, 912 F.2d 8 1090, 1092 (9th Cir. 1990) (citing McNutt v. Gen. Motors Acceptance Corp., 298 U.S. 178, 9 189 (1936)). Federal courts “possess only that power authorized by Constitution and 10 statute,” and therefore “[i]t is to be presumed that a cause lies outside this limited 11 jurisdiction.” Kokkonen v. Guardian Life Ins. Co. of Am., 511 U.S. 375, 377 (1994). In 12 effect, the court presumes lack of jurisdiction until the plaintiff proves otherwise. See id. 13 II. Analysis 14 Claims “arising under” the Medicare Act (“the Act”) are subject to judicial review 15 only if a plaintiff first exhausts their administrative remedies. See 42 U.S.C. §§ 405(g)– 16 (h); Heckler v. Ringer, 466 U.S. 602, 614–15 (1984); Do Sung Uhm v. Humana, Inc., 620 17 F.3d 1134, 1141 (9th Cir. 2010) (finding that the district court lacked jurisdiction over the 18 plaintiff’s claims because § 405(h)’s administrative exhaustion requirements were not 19 met). A claim arises under the Act in two circumstances: “(1) where the standing and the 20 substantive basis for the presentation of the claims is the Medicare Act, and (2) where the 21 claims are inextricably intertwined with a claim for Medicare benefits.” Uhm, 620 F.3d at 22 1141 (internal citation and quotation omitted). 23 Courts consider claims “inextricably intertwined” with the Act when they are 24 “[c]leverly concealed claims for benefits.” Kaiser v. Blue Cross of Cali., 347 F.3d 1107, 25 1112 (9th Cir. 2003) (quoting United States v. Blue Cross & Blue Shield of Ala., Inc., 156 26 F.3d 1098, 1109 (11th Cir. 1998)). This connection is based on the nature of the claim; 27 courts have recognized that both federal and state law claims can be inextricably 28 intertwined with the Act. See Kaiser, 347 F.3d at 1114 (citing Bodimetric Health Servs., Inc. v. Aetna Life & Cas., 903 F.2d 480, 487 (7th Cir. 1990); Dicrescenzo v. UnitedHealth 2\| Grp. Inc., No. CV 15-00021 DKW-RLP, 2015 WL 5472926, at *4 (D. Haw. Sept. 16, 2015). In Heckler, for example, “plaintiffs had formulated their claims under various sources of law other than the Medicare Act, including claims brought under the 5 || Constitution and under other statutes.” Uhm, 620 F.3d at 1141. The Supreme Court 6 || considered the claims as “at bottom, a claim that [the plaintiffs] should be paid for their [ ] 7\| surgery.” Heckler, 466 U.S. at 614. The Court reasoned that this was the case because, if 8 || the plaintiffs obtained a favorable ruling during an administrative appeal, “‘only essentially 9|| ministerial details [would] remain before [the plaintiffs] would receive reimbursement.” 7d. at 615. 11 Here, Plaintiff's claim is based on Defendant’s denial of coverage for a retreatment 12 || dental procedure which, left unperformed because of Defendant’s denial of coverage, 13 || caused him pain and suffering. (Doc. 1-3 at 6.) Because Plaintiff’s claims relate to delay in the coordination and approval for benefits, they are inextricably intertwined with the 15 | Medicare benefits decision, and Plaintiff must first present them to the Secretary. Plaintiff 16 || cannot disentangle his claims merely by alleging damages beyond reimbursement for his || retreatment procedure. See Quinones v. UnitedHealth Grp. Inc., No. CIV. 14-00497 LEK, 18 || 2015 WL 3965961, at *4 (D. Haw. June 30, 2015). Plaintiff does not allege that he first || presented his claims to the Secretary, arguing only in his Response that he called Defendant || and “appealed to its Complaint and Appeals Department.” (Doc. 15 at 1.) This unsupported allegation does not track the review and appeal requirements of the Act. 22 CONCLUSION 23 IT IS THEREFORE ORDERED that Defendant’s Motion to Dismiss (Doc. 5) is 24|| GRANTED. Plaintiff's Complaint is Dismissed with leave to file an amended complaint 25 || within 30 days of the date of this Order. 26 Dated this 30th day of July, 2021. ff Warrsay for) 28 . Murray Bnow Chief United states District Judge -3-