FOR PUBLICATION

UNITED STATES COURT OF APPEALS

FOR THE NINTH CIRCUIT

JOHN DOE, on behalf of himself and 

all others similarly situated, 

Plaintiff-Appellee, 

 v. 

CEDARS-SINAI HEALTH SYSTEM; 

CEDARS-SINAI MEDICAL 

CENTER, 

Defendants-Appellants.

No. 23-55466 

D.C. No. 

2:23-cv-00870-

DSF-JPR 

OPINION

JARROD BROWNE, 

Plaintiff-Appellee, 

 v. 

CEDARS-SINAI HEALTH SYSTEM; 

CEDARS-SINAI MEDICAL 

CENTER, 

Defendants-Appellants.

No. 23-55474 

D.C. No. 

2:23-cv-01551-

DSF-JPR 
2 DOE V. CEDARS-SINAI HEALTH SYSTEM

STEVEN BELTRAN; LISA 

REINGOLD, individually and on 

behalf of all others similarly situated, 

Plaintiffs-Appellees, 

 v. 

CEDARS-SINAI HEALTH SYSTEM; 

CEDARS-SINAI MEDICAL 

CENTER, 

Defendants-Appellants.

No. 23-55557 

D.C. No. 

2:23-cv-02626-

DSF-JPR 

Appeal from the United States District Court

for the Central District of California

Dale S. Fischer, District Judge, Presiding

Argued and Submitted April 10, 2024

Pasadena, California

Filed July 5, 2024

Before: Marsha S. Berzon and Salvador Mendoza, Jr., 

Circuit Judges, and Susan R. Bolton,* District Judge.

Opinion by Judge Mendoza

* The Honorable Susan R. Bolton, United States District Judge for the 

District of Arizona, sitting by designation.
DOE V. CEDARS-SINAI HEALTH SYSTEM 3 

SUMMARY**

Federal Officer Removal

The panel affirmed the district court’s orders remanding 

removed actions to state court based on a lack of federal 

officer jurisdiction under 28 U.S.C. § 1442(a)(1). 

Three sets of plaintiffs filed class-action lawsuits in state 

court against their healthcare provider, Cedars-Sinai Health 

System and Cedars-Sinai Medical Center, alleging that 

Cedars-Sinai unlawfully disclosed their private medical 

information to third parties through tracking software on its 

website. Cedars-Sinai removed the suits to federal court 

under § 1442(a)(1), arguing that it developed its website 

while acting under a federal officer and at the direction of 

the federal government. 

Following other circuits, the panel agreed with the 

district court that Cedars-Sinai developed its website in 

compliance with a generally applicable and comprehensive 

regulatory scheme under the Health Information Technology 

for Economic and Clinical Health Act, and that there was 

therefore no federal jurisdiction under 

§ 1442(a)(1). Although Cedars-Sinai’s website furthered 

the government’s broad goal of promoting access to digital 

health records, Cedars-Sinai’s relationship with the federal 

government did not establish that it acted pursuant to 

congressionally delegated authority to help accomplish a 

basic governmental task. Indeed, far from acting at the 

direction of a federal officer, Cedars-Sinai built a private 

** This summary constitutes no part of the opinion of the court. It has 

been prepared by court staff for the convenience of the reader.
4 DOE V. CEDARS-SINAI HEALTH SYSTEM

website of its own design to benefit its patients and 

staff. Accordingly, Cedars-Sinai did not meet 

§ 1442(a)(1)’s “causal nexus” requirement. 

COUNSEL

Rachele R. Byrd (argued), Wolf Haldenstein Adler Freeman 

& Herz LLP, San Diego, California; Brittany Scott and 

Lawrence T. Fisher, Bursor & Fisher PA, Walnut Creek, 

California; Scott R. Drury, Drury Legal LLC, Highwood, 

Illinois; Samuel M. Ward, Barrack Rodos & Bacine, San 

Diego, California; for Plaintiffs-Appellees.

Kyle T. Cutts (argued), Baker & Hostetler LLP, Cleveland, 

Ohio; Teresa C. Chow and Dyanne J. Cho, Baker & 

Hostetler LLP, Los Angeles, California; Paul G. Karlsgodt, 

Baker & Hostetler LLP, Denver, Colorado; Alexander 

Vitruk and James R. Morrison, Baker & Hostetler LLP, 

Seattle, Washington; for Defendant-Appellant. 

OPINION

MENDOZA, Circuit Judge:

As courts of limited jurisdiction, we are often precluded 

from hearing interesting and complex cases like the one 

before us today. Here, three sets of patients (“Plaintiffs”)

filed class-action lawsuits in state court against their 

healthcare provider, Defendants-Appellants Cedars-Sinai 

Health System and Cedars-Sinai Medical Center (“CedarsSinai”), alleging that Cedars-Sinai unlawfully disclosed their 
DOE V. CEDARS-SINAI HEALTH SYSTEM 5

private medical information to third parties through tracking 

software on its website. Cedars-Sinai removed the suits to 

federal court under 28 U.S.C. § 1442(a)(1), arguing that it 

developed its website while acting under a federal officer 

and at the direction of the federal government. The district 

court disagreed. Relevant here, the district court held that 

Cedars-Sinai developed its website in compliance with a 

generally applicable and comprehensive regulatory scheme

and that there is therefore no federal jurisdiction under 

§ 1442(a)(1). 

After considering Cedars-Sinai’s consolidated appeal, 

we agree with the district court’s decision. Although 

Cedars-Sinai’s website furthers the government’s broad goal 

of promoting access to digital health records, Cedars-Sinai’s 

relationship with the federal government does not establish 

that it acted pursuant to congressionally delegated authority 

to help accomplish a basic governmental task. Indeed, far 

from acting at the direction of a federal officer, Cedars-Sinai

built a private website of its own design to benefit its patients

and staff. Accordingly, we affirm the district court’s remand 

orders.

I.

In 2009, Congress passed the Health Information 

Technology for Economic and Clinical Health (“HITECH”) 

Act to encourage healthcare providers to digitize medical 

records and make them available online to patients and 

medical care providers. Pub. L. No. 111-5, §§ 13001–424, 

123 Stat. 115, 226–79 (2009); 42 U.S.C. § 300jj-11(b). 

Congress intended for these digital records—commonly 

referred to as electronic health records (“EHRs”)—to reduce 

medical errors and improve quality of care, permitting 

patients and providers to easily view and access a patient’s 
6 DOE V. CEDARS-SINAI HEALTH SYSTEM

medical history and facilitating the transfer of those records 

between facilities. The federal government established the

Office of the National Coordinator for Health Information 

Technology (“National Coordinator”), housed within the 

Department of Health and Human Services (“HHS”), to 

coordinate efforts like this, with the hope that the 

Coordinator might develop “a nationwide health information 

technology infrastructure that allows for the electronic use 

and exchange of information.” 42 U.S.C. § 300jj-11(a), (b); 

see also Exec. Order No. 13335, 69 Fed. Reg. 24059 (Apr. 

27, 2004).

The HITECH Act authorized HHS and its offices and 

agencies to promote the development of health information 

technology in a variety of ways. For example, the Act

directed HHS to make incentive payments, via 

reimbursement, to any Medicare-participating provider that 

is a “meaningful EHR user.” 42 U.S.C. § 1395w4(o)(1)(A)(i). The incentive payments were not available 

after 2016. Id. § 1395w-4(o)(1)(A)(ii); see also Martin v. 

LCMC Health Holdings, Inc., 101 F.4th 410, 413 (5th Cir. 

2024). Beginning in 2015, the law directed HHS to reduce 

Medicare reimbursement to any Medicare-participating 

provider that is “not a meaningful EHR user.” 42 U.S.C.

§ 1395w-4(a)(7). For its part, the Centers for Medicare and 

Medicaid Services (“CMS”), an agency within HHS, created 

the “Meaningful Use Program” to implement the HITECH 

Act. See 42 C.F.R. § 495 et seq. Under that program, CMS 

developed certain objectives and measures that providers 

must meet to qualify as “meaningful EHR user[s],” and thus 

receive incentive payments or avoid reduced Medicare 
DOE V. CEDARS-SINAI HEALTH SYSTEM 7

reimbursements.

1 42 C.F.R. §§ 495.20–495.24. HHS has 

repeatedly used its rulemaking procedures to revise these

objectives. But they have consistently included

(1) increasing engagement with digital health records and 

(2) providing patients the ability to view online, download, 

and transmit information about their health information or a 

hospital admission. 45 C.F.R. § 170.314(e)(1)(i);

2 see also 

42 C.F.R. §§ 495.20(f)(12)(i)(B) (applying before 2015); 

495.22(e)(8)(i), (i)(A)(1) (applying 2015 through 2018);

495.24(c)(5)(ii)(A)(1) (applying after 2019). To receive 

incentive payments, participating providers must submit a 

“Patient Engagement” or Interoperability Report attesting to 

the provider’s progress in accomplishing the Meaningful 

Use Program’s objectives. 45 C.F.R. § 170.314(e)(1)(i); 42 

C.F.R. § 495.24(d)(6)(ii)(B)(1). To meet these objectives, 

providers often develop “online patient portals,” or websites, 

to which patients and other users can login to view their 

EHRs. 

Cedars-Sinai, a healthcare organization based in 

California, has participated in the Meaningful Use Program 

since 2011. Like other participating healthcare providers, 

Cedars-Sinai developed a patient portal, called My CS-Link, 

1 Because the Medicare reimbursement penalty is one form of an 

incentive—in that the recipient receives more money for complying with 

the regulations than it does for not complying—we use the word 

“incentive” to refer both to the payments available through 2016 and the 

reimbursement penalty imposed after 2015.

2 It appears that 45 C.F.R. § 170.314 is no longer active. See 45 C.F.R. 

§ 170.314 (reserved); 21st Century Cures Act: Interoperability, 

Information Blocking, and the ONC Health IT Certification Program, 85 

Fed. Reg. 25642, 25651, 25655–56 (May 1, 2020). But Plaintiffs seek 

retrospective relief, so Cedars-Sinai’s conduct under § 170.314 remains 

relevant. 
8 DOE V. CEDARS-SINAI HEALTH SYSTEM

which is available on its website. Cedars-Sinai promotes the 

“convenience, functionality, and security” of the portal, 

advertising that it allows its patients to access their medical 

information and view test results, schedule appointments 

with providers, and research medical conditions. Relevant 

here, Cedars-Sinai’s website and portal incorporate a piece 

of code, developed by the technology company Meta 

Platforms, Inc. (formerly Facebook, Inc.), which enables its 

hospitals to “track and share data about customer 

transactions.” This code, colloquially called the “Meta 

Pixel,” tracks patients’ interactions with Cedars-Sinai’s 

website and portal and relays that information back to 

Cedars-Sinai and to Meta. Cedars-Sinai’s websites also use 

other website analytic tools, like Google Analytics 

“cookies,” to track and analyze patient interactions. To take 

advantage of federal incentive payments, Cedars-Sinai 

submits yearly Interoperability Reports, attesting to its

progress in implementing the Meaningful Use Program’s 

objectives and reporting on the success of My CS-Link. 

Cedars-Sinai’s website, and its use of the Meta Pixel and 

Google Analytics tools to track user interactions, prompted 

three separate class action lawsuits, each filed in California 

Superior Court. The Plaintiffs in the three suits assert both

overlapping and distinct claims,3 but their allegations share 

3 The first lawsuit, led by John Doe, asserts claims under the California 

Invasion of Privacy Act, Cal. Penal Code §§ 630–32; invasion of privacy 

and intrusion upon seclusion in violation of California common law and 

the California Constitution, art. 1, § 1; California’s Confidentiality of 

Medical Information Act, Cal. Civ. Code § 56 et seq.; and California’s 

Unfair Competition Law, Cal. Bus. & Prof. Code § 17200 et seq.; as well 

as claims for breach of contract, breach of the implied covenant of good 

faith and fair dealing, and negligence. The second lawsuit, led by Jarrod 
DOE V. CEDARS-SINAI HEALTH SYSTEM 9

a common thread: Cedars-Sinai violated California law and 

breached its own privacy policies by using the Meta Pixel 

and Google Analytics tools to track and disclose sensitive 

medical information reflected in user interactions on CedarsSinai’s website. According to Plaintiffs, the Meta Pixel 

intercepted and relayed information about Plaintiffs to Meta 

and other companies, including those patients’ Facebook ID 

numbers, information about their appointments, and the 

search terms they used while researching health conditions. 

Those patients’ Facebook ID numbers can be connected to 

patients’ names on Facebook, meaning that “the private 

medical information a person enters onto [Cedars-Sinai’s]

Website” is “easily linked to the person themselves.” Based 

on this conduct, each Plaintiff seeks remedies for violations 

of California law; no Plaintiff alleges claims under federal 

law. 

Cedars-Sinai removed each lawsuit from state court to 

federal court, and each Plaintiff timely moved for the federal 

court to remand his or her lawsuit to state court. In 

opposition to Plaintiffs’ motions for remand, Cedars-Sinai 

argued that removal was warranted under 28 U.S.C. 

§ 1442(a)(1) because it “acted under” a federal officer when 

it developed My CS-Link. The district court disagreed and 

granted Plaintiffs’ motions to remand, in three separate 

Browne, asserts claims under the California Invasion of Privacy Act, 

California’s Confidentiality of Medical Information Act, and the 

California Constitution. The third lawsuit, filed by Steven Beltran and 

Lisa Reingold, brings claims for negligence, negligence per se, breach of 

implied contract, breach of the implied covenant of good faith and fair 

dealing, breach of fiduciary duty, breach of duty, as well as violations of 

the California Invasion of Privacy Act, California’s Confidentiality of 

Medical Information Act, California’s Unfair Competition Law, and the 

California Constitution.
10 DOE V. CEDARS-SINAI HEALTH SYSTEM

orders. The court reasoned that Cedars-Sinai’s compliance 

with a comprehensive regulatory scheme, even when 

accompanied by governmental supervision and monitoring, 

does not mean that it “acted under” a federal officer 

sufficiently to permit federal officer jurisdiction under 

§ 1442(a)(1). According to the district court, “[t]he 

directions Cedars-Sinai points to are general regulations and 

public directives regarding the development of health 

information technology and electronic health records 

infrastructure,” and “removal is not justified.” Cedars-Sinai 

timely appealed each order. Those appeals were 

consolidated before this court.

II.

“[U]nlike garden-variety remand orders for lack of 

subject-matter jurisdiction or defects in removal procedure, 

which are not appealable,” remand orders rejecting federal 

officer removal under § 1442(a)(1) are appealable under 28 

U.S.C. § 1447(d). DeFiore v. SOC LLC, 85 F.4th 546, 554 

(9th Cir. 2023); see also City of Honolulu v. Sunoco LP, 39 

F.4th 1101, 1106 (9th Cir. 2022). We review de novo a 

district court’s decision to remand a removed case. Cabalce 

v. Thomas E. Blanchard & Assocs., Inc., 797 F.3d 720, 727 

(9th Cir. 2015).

III.

Although Cedars-Sinai unilaterally removed these statecourt actions to federal court, that fact does not mean that 

they get to stay there. The federal officer removal statute 

permits removal of actions brought in state court against 

“any officer (or any person acting under that officer) of the 

United States or of any agency thereof . . . for or relating to 

any act under color of such office.” 28 U.S.C. § 1442(a)(1). 

To satisfy this requirement, a removing entity must establish 
DOE V. CEDARS-SINAI HEALTH SYSTEM 11

that: “(a) it is a person within the meaning of the statute; 

(b) there is a causal nexus between its actions, taken 

pursuant to a federal officer’s directions, and [the] plaintiff’s 

claims; and (c) it can assert a colorable federal defense.” 

County of San Mateo v. Chevron Corp., 32 F.4th 733, 755 

(9th Cir. 2022) (quoting Riggs v. Airbus Helicopters, Inc., 

939 F.3d 981, 986–87 (9th Cir. 2019)). Unlike removal 

under § 1441,4 which is construed narrowly, federal officer

removal “must be ‘liberally construed.’” DeFiore, 85 F.4th 

at 553–54 (quoting Watson v. Philip Morris Cos., Inc., 551 

U.S. 142, 147 (2007)). But even though removal rights 

under the federal officer removal statute “are much broader 

than those under section 1441,” Durham v. Lockheed Martin 

Corp., 445 F.3d 1247, 1253 (9th Cir. 2006), the statute’s 

“broad language is not limitless,” Watson, 551 U.S. at 147. 

We may not interpret the federal officer removal statute 

considerably beyond its reach, “potentially bringing within 

its scope state-court actions filed against private firms in 

many highly regulated industries.” Chevron, 32 F.4th at 757

(quoting Watson, 551 U.S. at 153). 

Neither party disputes that Cedars-Sinai is a “person” 

within the meaning of § 1442(a)(1).5 But they disagree as to

whether Cedars-Sinai can (1) establish a causal nexus 

between federally directed conduct and Plaintiffs’ claims, or

(2) assert colorable federal defenses to Plaintiffs’ state-law

claims. Because we find that Cedars-Sinai cannot show that 

its development of a website and portal with embedded 

4 Section 1441(a) provides that “any civil action brought in a State court 

of which the district courts of the United States have original jurisdiction, 

may be removed” to federal court.

5 Our precedent confirms as much. See DeFiore, 85 F.4th at 553 (noting 

that “corporations” are persons for purposes of § 1442(a)(1)). 
12 DOE V. CEDARS-SINAI HEALTH SYSTEM

tracking technology was federally directed, we affirm the 

district court’s remand orders on that basis and do not 

address whether it can assert colorable federal defenses. See 

Chevron, 32 F.4th at 760.

A.

To satisfy § 1442(a)(1)’s “causal nexus” requirement, 

Cedars-Sinai must demonstrate that it was “acting under” a 

federal officer in performing some “act under color of 

federal office,” i.e., that it was “involved in ‘an effort to 

assist, or to help carry out, the duties or tasks of the federal 

superior.’” Goncalves ex rel. Goncalves v. Rady Childs.

Hosp. San Diego, 865 F.3d 1237, 1245 (9th Cir. 2017)

(quoting Watson, 551 U.S. at 152). The Supreme Court’s 

decision in Watson v. Philip Morris Cos., Inc. guides our 

analysis. There, the Court addressed federal officer removal 

in a lawsuit challenging a defendant cigarette company’s 

advertising of “light” cigarettes. 551 U.S. at 146. The 

defendant sought removal based on its use of governmentapproved cigarette-testing methods, asserting that its

compliance with the government’s testing requirements 

satisfied § 1442(a)(1)’s “acting under” element. Id. at 146–

47. The Court disagreed. Drawing on § 1442(a)(1)’s history 

and text, the Watson Court considered multiple cases where 

courts have authorized federal officer removal. See id. at 

148–51 (citing, e.g., Mesa v. California, 489 U.S. 121

(1989); Willingham v. Morgan, 395 U.S. 402 (1969); and 

Tennessee v. Davis, 100 U.S. 257 (1880)). It reasoned that 

“the removal statute’s ‘basic’ purpose is to protect the 

Federal Government from the interference with its 

‘operations’ that would ensue were a State able, for example, 

to ‘arres[t]’ and bring ‘to trial in a State cour[t]’” officers or 

agents of the federal government acting “‘within the scope 

of their authority.’” Id. at 150 (alterations in original)
DOE V. CEDARS-SINAI HEALTH SYSTEM 13

(quoting Willingham, 395 U.S. at 406). Thus, the mere “fact 

that a federal regulatory agency directs, supervises, and 

monitors a company’s activities in considerable detail” does 

not mean the company acts under a federal officer for 

removal purposes. Id. at 145. Something more must be 

present, like the “delegation of legal authority,” which might 

include “evidence of any contract, any payment, any 

employer/employee relationship, or any principal/agent 

arrangement.” Id. at 156. 

In Chevron, we distilled Watson into several factors, 

each of which may aid our determination of whether “a 

private person is ‘acting under’ a federal officer.” 32 F.4th 

at 756. Although non-exhaustive, those factors include:

[W]hether the person is acting on behalf of 

the officer in a manner akin to an agency 

relationship. The Court also considers 

whether the person is subject to the officer’s 

close direction, such as acting under the 

“subjection, guidance, or control” of the 

officer, or in a relationship which “is an 

unusually close one involving detailed 

regulation, monitoring, or supervision.” 

Third, the Court considers whether the 

private person is assisting the federal officer 

in fulfilling “basic governmental tasks” that 

“the Government itself would have had to 

perform” if it had not contracted with a 

private firm. Finally, taking into account the 

purpose of § 1442(a)(1), the Court has 

considered whether the private person’s 

activity is so closely related to the 

government’s implementation of its federal 
14 DOE V. CEDARS-SINAI HEALTH SYSTEM

duties that the private person faces “a 

significant risk of state-court ‘prejudice,’” 

just as a government employee would in 

similar circumstances, and may have 

difficulty in raising an immunity defense in 

state court.

Id. at 756–57 (citations omitted) (discussing Watson, 551 

U.S. at 151–54); see also Cabalce, 797 F.3d at 729; 

Goncalves, 865 F.3d at 1246–47; Leite v. Crane Co., 749 

F.3d 1117, 1120, 1124 (9th Cir. 2014). 

Our circuit has not yet applied these Watson-derived

factors to address whether a healthcare provider acts at the 

direction of the National Coordinator when it creates an 

EHR website with an embedded tracking code. Thankfully, 

we are not staring at blank computer screens, learning how 

to program “Hello, World!”6 The Third, Fifth, and Eighth 

Circuits have each considered this issue, and all three have

held that the federal officer removal statute does not support 

removal for suits challenging conduct like Cedars-Sinai’s. 

We start with the first mover: the Eighth Circuit in Doe 

v. BJC Health System, 89 F.4th 1037, 1043 (8th Cir. 2023). 

Like Cedars-Sinai, the BJC Health System defendant created 

an online portal for its patients to access EHRs, and that 

portal contained tracking code that allegedly disclosed those 

patients’ private data to third parties, including Meta and 

Google LLC. Id. at 1040–41. In response to the plaintiffs’ 

motion to remand, the BJC Health System defendant invoked 

6 To ruin a joke with explanation: when students learn a new 

programming language, they often start by creating a computer program 

that displays the message “Hello, World!” See Brian W. Kernighan & 

Dennis Ritchie, The C Programming Language 9–10 (1st ed. 1978).
DOE V. CEDARS-SINAI HEALTH SYSTEM 15

federal officer removal jurisdiction, arguing that “when it 

created and operated the portal, it acted under HHS’s or the 

[National] Coordinator’s authority.” Id. at 1041. The Eighth 

Circuit was not persuaded. Relying on Watson, it reasoned

that § 1442(a)(1) permits removal only when a defendant 

“performs a ‘basic governmental task’” that “involves a 

‘delegation of legal authority’ from a federal entity.” Id. at 

1043 (quoting Watson, 551 U.S. at 153, 156). Although it 

conceded that the development of EHRs may well be 

“important” under the HITECH Act and Meaningful Use 

Program, the court held that “[t]he design of private websites 

is not—and has never been—a basic governmental task.” Id. 

at 1045. Instead, the defendant “created and operated an 

online portal for its patients,” essentially “doing its own” 

business. Id. So reasoning, the Eighth Circuit affirmed the 

district court’s order, finding that the defendant’s 

development of “a private website” and receipt of “a federal 

subsidy” was “insufficient for removing a case under 28 

U.S.C. § 1442(a)(1).” Id. at 1047.

Not long after the Eighth Circuit’s decision in BJC 

Health System, the Third Circuit issued its decision in Mohr 

v. Trustees of the University of Pennsylvania, 93 F.4th 100, 

103 (3d Cir. 2024). It too rejected the defendant’s theory 

that it acted under a federal officer when it shared “patients’ 

identities, sensitive health information, and online activity 

from its patient portals with Facebook in violation of [state] 

privacy law.” Id. Relying heavily on BJC Health System

and Watson, the Mohr court considered whether the 

government delegated legal authority pursuant to the 

Meaningful Use Program and HITECH Act to the defendant 

“to operate a patient portal on behalf of the government.” Id. 

at 105. Like the BJC Health System court, it answered “no.” 

The Third Circuit reasoned that the defendant had merely 
16 DOE V. CEDARS-SINAI HEALTH SYSTEM

demonstrated “compliance with federal laws and 

regulations” when operating its own portal, which is 

insufficient to show that it had acted at the direction of a 

federal officer. Id. at 105 (citation and internal quotation 

marks omitted). After all, “[a]dvancing governmental policy 

while operating one’s own business is not the same as 

executing a delegated governmental duty.” Id. The court 

also dismissed the defendant’s argument that its “contractual 

relationship” with the federal government permitted 

removal. Id. at 105–06. Invoking Watson, the Mohr court 

dug into the “nature of the relationship between the private 

party and the federal government,” and found that the 

defendant was “not producing or operating any patient portal 

for the government.” Id. (citing Watson, 551 U.S. at 152–

54). So the Third Circuit also affirmed remand.

The Fifth Circuit joined the Eighth and Third Circuits

with its decision in Martin v. LCMC Health Holdings, Inc.,

101 F.4th 410, 412 (5th Cir. 2024). The Martin defendant, 

like the defendants in the Eighth and Third Circuit cases,

sought removal in an action alleging that it “embedded 

tracking pixels onto its website that shared [the plaintiff’s] 

private health information with third-party websites.” Id. It 

too urged the court to find that it acted under the National 

Coordinator, pursuant to the HITECH Act and the 

Meaningful Use Program, when it “created and operated its 

online portal, accepted federal incentive payments, and 

potentially incurred liability under [state] law through its use 

of tracking pixels.” Id. at 414–15. The Martin court, 

echoing Mohr and BJC Health System, invoked Watson and 

held that the defendant “cannot show that its relationship 

with the government involved anything more than 

regulation.” Id. at 415–16 (citing Watson, 551 U.S. at 152–

57). Like the defendants in those other cases, the Martin 
DOE V. CEDARS-SINAI HEALTH SYSTEM 17

defendant “did not assist or carry out any tasks of the 

government”; it was not an “instrumentality of the 

government”; and its “online patient portal was operated by 

[the defendant] and existed for the benefit of [the 

defendant’s] patients and staff.” Id. at 415. Accordingly, 

“[t]he operation of the online patient portal [was] not 

pursuant to a federal officer’s directive because the federal 

government would not have created an online patient portal 

if [the defendant] had chosen not to do so.” Id. (citing BJC 

Health Sys., 89 F.4th at 1047; Mohr, 93 F.4th at 105). Thus, 

the healthcare provider’s “relationship with the federal 

government [was] too attenuated to show any delegation of 

legal authority” to permit removal of plaintiff’s lawsuit. Id.

at 416.

B.

Here, Cedars-Sinai presents many of the same arguments 

in favor of removal as the BJC Health System, Mohr, and 

Martin defendants. Like those defendants, Cedars-Sinai

points to the HITECH Act’s and Meaningful Use Program’s 

directives, arguing that the federal government regulated and 

monitors its development of the My CS-Link portal and 

associated website. Cedars-Sinai also argues that it is 

helping the government produce a nationwide, interoperable 

technology infrastructure for health information and, absent 

its assistance, the National Coordinator would be left to 

complete his mission alone. Finally, Cedars-Sinai points to 

its past receipt of federal incentive payments and its

continuing efforts to avoid reduced Medicare reimbursement 

payments through compliance with federal reporting

requirements as evidence of delegated government 

authority. Like our sister circuits, we are unpersuaded by 

these arguments.
18 DOE V. CEDARS-SINAI HEALTH SYSTEM

First, we agree with BJC Health System: Cedars-Sinai 

did not assist the National Coordinator with delegated “basic 

governmental tasks” when it built its patient portal and 

website using tracking technology. See 89 F.4th at 1043. As 

the Watson Court noted, § 1442(a)(1) does not permit 

removal just because “a federal regulatory agency directs, 

supervises, and monitors a company’s activities in 

considerable detail.” 551 U.S. at 145. Acting under a federal 

officer entails more than “simply complying with the law”; 

it requires “helping the Government to produce an item that 

it needs.” Id. at 152–53 (second emphasis added). This 

generally involves a “delegation of legal authority” from a 

federal entity. Id. at 156. In City of Honolulu v. Sunoco LP, 

for example, we rejected multiple theories of federal officer

removal jurisdiction related to the defendant’s production of 

oil and gas through offshore drilling operations. 39 F.4th at

1107–10. Despite Congress’s oversight of those offshoredrilling leases and its recognition that “offshore oil resources 

are a national security asset,” we reasoned that offshore 

drilling and oil production is not a “basic governmental

task.” Id. at 1108–09. It is, instead, a highly regulated 

industry that the defendants entered. Id. By contrast, in 

Goncalves, we found federal officer jurisdiction warranted 

over claims arising from the defendant’s administration of a 

federally created health-insurance plan. 865 F.3d at 1246. 

But we did so because the Goncalves defendant acted 

pursuant to an express delegation of responsibility by 

Congress, essentially fulfilling the role of a claims processor 

for the government. Id. at 1246–47. 

Cedars-Sinai’s conduct more closely resembles the

Watson and Sunoco defendants’ conduct than the Goncalves

defendant’s conduct. Unlike the defendant in Goncalves, or 

even the analogous healthcare provider in Mohr, Cedars-
DOE V. CEDARS-SINAI HEALTH SYSTEM 19

Sinai does not allege that it has contracted with the 

government to provide a service or to create a product on its 

behalf. See Goncalves, 865 F.3d at 1246; Mohr, 93 F.4th at 

105–06. Instead, Cedars-Sinai has presented evidence that 

it has complied with the broad requirements of the HITECH 

Act, which apply to any healthcare provider participating in 

the Meaningful Use Program. That Program’s requirements 

do not show an express delegation of authority to CedarsSinai to accomplish a basic governmental task on the 

National Coordinator’s behalf. Far from it. Cedars-Sinai 

chose to satisfy the Meaningful Use Program’s objectives by 

building a patient portal using tracking technology. That 

decision does not mean Cedars-Sinai’s My CS-Link is a 

federal government website, or that it is operated on the 

government’s behalf or for the federal government’s benefit. 

To be sure, Cedars-Sinai’s conduct might “advance the 

government’s policy by operating a patient portal that meets 

certain objectives and measures.” Mohr, 93 F.4th at 105.

But the portal is the healthcare provider’s creation, and there 

is no evidence that the government would create such a 

portal absent Cedars-Sinai’s participation. See Martin, 101 

F.4th at 415. Put simply, it is a private website, built by a 

private entity, to serve that private entity’s patients and staff. 

Given that context, Cedar Sinai cannot establish that it is a 

subject of the government’s direction, thus entitling it to a 

federal forum to put on its federal defenses. 

Anticipating this conclusion, Cedars-Sinai asks us to 

consider the government’s requirements in 42 C.F.R. 

§ 495.20(f)(12)(i)(B) and 45 C.F.R. § 170.314(e)(1)(i). But 

neither of those regulations delegate legal authority to 

accomplish a basic governmental task. Section 

495.20(f)(12)(i)(B) states that an objective of the 

Meaningful Use Program is to “provide patients the ability 
20 DOE V. CEDARS-SINAI HEALTH SYSTEM

to view online, download, and transmit information about a 

hospital admission.” Likewise, § 170.314(e)(1)(i) requires 

healthcare providers to submit Interoperability Reports on 

“[p]atient engagement” with “EHR technology” that 

“provide[s] patients . . . with an online means to view, 

download, and transmit to a 3rd party” certain specified data. 

These regulations do not require Cedars-Sinai to build a 

specific type of website or patient portal—much less a portal 

that uses the tracking technology described in the complaint. 

Nor do they impose sufficient federal oversight to 

demonstrate that Cedars-Sinai acted under the direction of a 

federal officer. Watson, 551 U.S. at 155–56 (rejecting 

federal officer removal jurisdiction, even though defendant 

“assumed responsibility for cigarette testing,” permitted a 

federal agency “to monitor the process closely,” and 

reported its results to a federal agency). Instead, the 

regulations grant healthcare providers considerable 

discretion to accomplish the Program’s goals, without the 

“requisite federal control or supervision” that might warrant 

the exercise of federal officer jurisdiction. Cabalce, 797 

F.3d at 728. 

Nor do we agree that Cedars-Sinai’s receipt of federal 

“incentive payments” warrants the exercise of federal officer

removal jurisdiction. The Watson Court indicated that 

evidence of “payment” might show that a defendant acted 

under color of federal authority. 551 U.S. at 156. But it

meant “payment” of the type arising from a “contract,” 

“employer/employee relationship, or any principal/agent 

arrangement.” Id. Neither the Supreme Court nor this court 

has held that federal incentives for compliance with federal 

regulations constitutes “payment” sufficient to render 

federal officer removal appropriate. Indeed, at least two of 

our sister circuits have squarely held the opposite. See Mays 
DOE V. CEDARS-SINAI HEALTH SYSTEM 21

v. City of Flint, 871 F.3d 437, 444 (6th Cir. 2017) (“[T]he 

receipt of federal funding alone cannot establish a delegation 

of legal authority.”); see also BJC Health Sys., 89 F.4th at

1045 (citing Mays and reasoning similarly); cf. Mohr, 93 

F.4th at 105–06 (rejecting argument that incentive payments 

indicate that the defendant acted as a government 

contractor); Martin, 101 F.4th at 414–15 (impliedly 

dismissing argument that acceptance of “federal incentive

payments” showed the defendant “acted ‘pursuant to’ a 

federal officer’s direction”). In our view, construing Watson 

to permit removal based on incentive payments would open 

the floodgates to a myriad of entities hoping to invoke 

federal officer removal jurisdiction, impermissibly 

expanding the scope of § 1442(a)(1) beyond its purview. Cf. 

Watson, 551 U.S. at 153. That view is not supported by the 

removal statute, precedent, or the specific facts of this case.

IV.

Our decision today puts us in good company, and 

Cedars-Sinai provides no “compelling reason” to “create a 

circuit split” by expanding the reach of federal officer 

removal jurisdiction. Padilla-Ramirez v. Bible, 882 F.3d 

826, 836 (9th Cir. 2017). So we decline its invitation to do 

so, and we affirm the district court’s remand orders.

AFFIRMED.