Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_19-cv-05804/USCOURTS-azd-2_19-cv-05804-0/pdf.json

Nature of Suit Code: 110
Nature of Suit: Insurance
Cause of Action: 28:1441 Petition for Removal- Tort/Non-Motor Vehicle

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WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Lafayette Moses,

Plaintiff,

v. 

United Healthcare Corporation, et al.,

Defendants.

No. CV-19-05804-PHX-DWL

ORDER 

Pending before the Court is Defendant UnitedHealthcare Insurance Company’s 

(“UHIC”) motion to dismiss under Federal Rules of Civil Procedure 12(b)(1) and 12(b)(6). 

(Doc. 8.) For the following reasons, that motion will be granted and this action will be 

terminated.

BACKGROUND

I. Factual Background

The facts alleged in the complaint, which are presumed to be true for purposes of 

the motion to dismiss, are as follows.

On or around October 10, 2014, pro se Plaintiff LaFayette Moses enrolled in a 

Medicare Supplement Plan issued by UHIC. (Doc. 1-3 at 6 ¶ 3.) 

Moses enrolled in the plan by telephone, and during that call a UHIC representative 

asked him if he had a current primary care physician. (Id. ¶¶ 4-5.) Moses stated that he 

did, and that the physician’s name was Dr. William Womack, and the UHIC representative 

responded by saying that Dr. Womack was in UHIC’s network and that Moses would be 

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allowed to retain Dr. Womack as his primary care physician. (Id.)

After this call, Moses received his membership identification card in the mail from 

UHIC, which did not reflect that Dr. Womack was his primary care physician. (Id. ¶ 6.) 

Moses called UHIC to ask why Dr. Womack’s name was omitted from his card, and the 

UHIC representative apologized and told him he would receive a new identification card 

with Dr. Womack’s name listed. (Id. at 7 ¶ 7.) 

Moses never received the corrected identification card. (Id. ¶ 8.) Over the next few 

years, Moses periodically called UHIC to request a corrected card, and each time UHIC 

representatives promised to send him a new card. (Id. ¶ 9.) Each replacement card assigned 

Moses a different primary care physician. (Id.)

On or around January 7, 2018, Moses suffered a severe head, ankle, knee, and pelvis 

injury. (Id. ¶ 10.) He received emergency care using his UHIC identification card and 

followed up with Dr. Womack. (Id.) 

On September 10, 2018, Moses visited an orthopedic surgeon for “very necessary 

prescribed follow-up care.” (Id. at 8 ¶ 14.) UHIC denied the follow-up care without 

explanation. (Id.)

Following this denial of follow-up care, Moses called UHIC numerous times and 

was met with “a consistent pattern of obscurity.” (Id. at 9 ¶ 22.) The UHIC representatives 

would advise Moses to call a particular person, and that person would advise Moses to call 

another. (Id. ¶ 23.) None of these individuals approved Moses’s follow-up care. (Id.) 

UHIC representatives also, at other times, denied that Dr. Womack was in UHIC’s 

network, denied that they had received a request for Moses to see an orthopedic surgeon, 

and “invalidated” Dr. Womack. (Id. at 11 ¶¶ 41-43.)1

...

...

1 Additionally, Moses contends in his response to UHIC’s motion to dismiss that, 

between June 14, 2019, and November 22, 2019, he sent several letters to the Department 

of Health and Human Services (“HHS”). (Doc. 11 at 2-3.) The first correspondence was 

a “report” detailing UHIC’s alleged failings. (Id. at 2.) Subsequent correspondence to 

HHS complained about HHS forwarding this report to Moses’s current insurance company, 

which played no role in UHIC’s denial of care. (Id. at 2-3.)

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II. Procedural Background

On November 7, 2019, Moses initiated this lawsuit by filing a complaint in 

Maricopa County Superior Court. (Doc. 1-3 at 5-14.)

On December 12, 2019, UHIC removed the action to this Court. (Doc. 1.)

On December 19, 2019, UHIC filed its motion to dismiss. (Doc. 8.)

On January 27, 2020, Moses filed a response. (Doc. 11.)

On February 7, 2020, UHIC filed a reply. (Doc. 12.)

On February 18, 2020, Moses filed a collection of “prima facie evidence.” (Doc. 

13.)

DISCUSSION

Moses’s complaint asserts ten claims against UHIC: (1) negligence, (2) conspiracy, 

(3) discrimination, (4) intentional infliction of emotional distress, (5) negligent infliction 

of emotional distress, (6) negligent training and supervision, (7) conversion, (8) tortious 

breach of contract, (9) breach of contract, and (10) punitive damages. (Doc. 1-3.) UHIC 

moves to dismiss on the grounds that (1) Moses has failed to state a claim and (2) the Court 

lacks jurisdiction over Moses’s claims due to his failure to exhaust administrative remedies. 

(Doc. 8.) Because the second argument is dispositive, there is no need to address UHIC’s 

other points.

I. Legal Standard

Rule 12(b)(1) of the Federal Rules of Civil Procedure provides that a defendant may 

move to dismiss an action for “lack of subject-matter jurisdiction.” “[I]n reviewing a Rule 

12(b)(1) motion to dismiss for lack of jurisdiction, we take the allegations in the plaintiff’s 

complaint as true.” Wolfe v. Strankman, 392 F.3d 358, 362 (9th Cir. 2004). The plaintiff 

bears the burden of establishing that subject matter jurisdiction exists. Kokkonen v. 

Guardian Life Ins. Co. of Am., 511 U.S. 375, 377 (1994). Failure to exhaust administrative 

remedies may be a barrier to federal jurisdiction under Rule 12(b)(1). See, e.g., Munns v. 

Kerry, 782 F.3d 402, 413 (9th Cir. 2015). 

The Court also notes that Moses is proceeding pro se, so his complaint “must be 

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held to less stringent standards than formal pleadings drafted by lawyers.” Hebbe v. Pliler, 

627 F.3d 338, 342 (9th Cir. 2010) (citing Erickson v. Pardus, 551 U.S. 89, 94 (2007)). 

Courts “have an obligation where the petitioner is pro se . . . to construe the pleadings 

liberally and to afford the petitioner the benefit of any doubt.” Bretz v. Kelman, 773 F.2d 

1026, 1027 n.1 (9th Cir. 1985).

II. Administrative Exhaustion

“Judicial review of claims arising under the Medicare Act is available only after the 

Secretary [of Health and Human Services] renders a ‘final decision’ on the claim, in the 

same manner as is provided in 42 U.S.C. § 405(g).” Heckler v. Ringer, 466 U.S. 602, 605 

(1984). “[A] ‘final decision’ is rendered on a Medicare claim only after the individual 

claimant has pressed his claim through all designated levels of administrative review.” Id. 

at 606. 

UHIC is a Medicare Advantage Organization (“MAO”), meaning it is a private 

insurance company that administers enrollees’ Medicare benefits under the directives of 

the Centers for Medicare and Medicaid Services (“CMS”). (Doc. 8 at 2-3.) CMS 

regulations govern the process for administratively challenging a denial of benefits by a 

MAO (such as UHIC) and are laid out at 42 C.F.R. § 422.560-422.626. See generally 

Prime Healthcare Huntington Beach, LLC v. SCAN Health Plan, 210 F. Supp. 3d 1225, 

1229 (C.D. Cal. 2016) (discussing the administrative review process for benefits 

determinations by MAOs). “Section 405(g) applies to the MAO review process.” Id. 

Thus, “where suit is brought against an MAO, § 405(h) limits [district courts’] jurisdiction 

over unexhausted claims to those that do not ‘arise under’ Medicare.” Id. at 1231. See 

also Tenet Healthsystem GB, Inc. v. Care Improvement Plus S. Cent. Ins. Co., 875 F.3d 

584, 587 (11th Cir. 2017) (“A party may only bring suit in an Article III court to challenge 

an [MAO] determination once all of the administrative remedies provided by the Act and 

its regulations have been exhausted. This is the sole pathway through which a party can 

obtain judicial review of any claim ‘arising under’ the Medicare Act.”) (citation omitted).

Here, Moses has not exhausted his administrative remedies against UHIC. 

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Although Moses contends that he has complained to UHIC and HHS about the incidents 

giving rise to this lawsuit (Doc. 1-3 at 9; Doc. 11 at 2-3), he does not allege—let alone 

present evidence—that he appealed to a private independent contractor pursuant to 42 

C.F.R. § 422.592, requested a hearing before an administrative law judge (“ALJ”) pursuant 

to 42 C.F.R. § 422.600, or requested review of the ALJ’s decision by the Medicare Appeals 

Council (“Council”) pursuant to 42 C.F.R. § 422.608. Because there is no final decision

as required by Section 405(g), the Court cannot review Moses’s claims arising under the 

Medicare Act. See, e.g., Kaiser v. Blue Cross of California, 347 F.3d 1107, 1116 (9th Cir. 

2003) (“Because the plaintiffs have not exhausted available administrative review, the 

district court lacked jurisdiction to consider those of their claims that arise under Medicare, 

and dismissal on those claims is affirmed.”).

Moses cites the “Patient Rights Act” as allowing him to commence an action 

without exhausting administrative remedies. (Doc. 11 at 4-6.) The Act states, in relevant 

part, that “[a]n action under this subsection may be commenced, and relief may be granted, 

without regard to whether the party commencing the action has sought or exhausted 

available administrative remedies.” S. 1993, 116th Cong. § 3(e)(2). The Act, however, 

has not been enacted into law. Additionally, it’s not clear how Moses’s claims would be 

considered a failure on the part of UHIC to exercise the “same degree of professional skill, 

care, and diligence to preserve the life and health of any patient as a reasonably diligent 

and conscientious health care practitioner would render to a patient in a different state of 

functionality, development, or degree of dependence.” Id. § 2(a)(1). Moses’s reliance on 

the “Patient Rights Act” is therefore unavailing. 

III. “Arising Under” The Medicare Act

The remaining question is whether Moses’s claims arise under the Medicare Act. 

“The Supreme Court has identified two circumstances in which a claim ‘arises under’ the 

Medicare Act: (1) where the standing and the substantive basis for the presentation of the 

claims is the Medicare Act; and (2) where the claims are inextricably intertwined with a 

claim for Medicare benefits.” Do Sung Uhm v. Humana, Inc., 620 F.3d 1134, 1141 (9th 

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Cir. 2010) (internal quotations omitted). “Most courts forego the ‘standing and substantive 

basis’ test in favor of the ‘inextricably intertwined’ test where plaintiffs do not invoke 

Medicare in their complaints.” Prime Healthcare, 210 F. Supp. 3d at 1232. “A claim is 

‘inextricably intertwined’ [with the Medicare Act] if it does not involve issues separate 

from the party’s claim that it is entitled to benefits and/or if those claims are not completely 

separate from its substantive claim to benefits.” Pinnacle Peak Neurology LLC v. Noridian 

Healthcare Sols. LLC, 2018 WL 10357126, *4 (D. Ariz. 2018) (citation omitted). “In 

assessing whether a claim falls into either of these categories, courts must discount any 

creative pleading which may transform Medicare disputes into mere state law claims, and 

painstakingly determine whether such claims are ultimately Medicare disputes.” Id. 

(internal quotations omitted). “[W]here, at bottom, a plaintiff is complaining about the 

denial of Medicare benefits . . . the claim ‘arises under’ the Medicare Act.” Uhm, 620 F.3d 

at 1142-43.

Here, Moses’s claims, although couched as claims arising under state law, either 

directly concern the denial of Medicare benefits or are not completely separate from 

Moses’s substantive claim for benefits. The alleged wrong upon which Moses’s claims for 

negligence, discrimination, conversion, tortious breach of contract, and breach of contract 

are all premised is the denial of follow-up care. (See, e.g., Doc. 11 at 7 [“Defendant(s) 

have never uttered a word as to why medical follow-up care by a legitimate Medicare 

approved physician was denied.”].) Similarly, Moses’s claims for conspiracy and 

negligent training and supervision concern his interactions with UHIC representatives 

relating to his efforts to manage and secure benefits, which other courts in this circuit have 

held to be inextricably intertwined with claims for Medicare benefits. See, e.g., 

DiCrescenzo v. UnitedHealth Grp. Inc., 2015 WL 5472926, *3 (D. Haw. 2015) (“Insofar 

as DiCrescenzo’s claims relate to the delay or mishandling of the coordination of benefits 

. . . , they are inextricably intertwined with a Medicare benefits decision, and DiCrescenzo 

must first present them to the Secretary [of HHS].”). Moses’s remaining claims—

intentional infliction of emotional distress, negligent infliction of emotional distress, and 

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punitive damages—simply assert that the behavior of UHIC and its representatives as set 

forth in the complaint is sufficient to sustain these respective claims. Such claims are 

inextricably intertwined with Moses’s claim for benefits and therefore arise under the 

Medicare Act.

The Court is cognizant of Moses’s pro se status and sympathetic to his frustration 

with what he alleges to be a Kafkaesque UHIC bureaucracy. Nevertheless, his claims are, 

at bottom, complaints about the denial of Medicare benefits. Judicial review of such claims 

is impermissible without a final administrative decision.

Accordingly, IT IS ORDERED that:

(1) UHIC’s motion to dismiss (Doc. 8) is granted.

(2) This action is terminated and the Clerk of Court shall enter judgment 

accordingly.

Dated this 28th day of April, 2020.

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