Opinion ID: 2978563
Heading Depth: 3
Heading Rank: 2

Heading: sufficiency of the evidence

Text: Martinez also argues that the evidence is insufficient to support his convictions. In particular, he contends that the evidence was insufficient to support his conviction for the distribution of controlled substances outside the bounds of medical practice and for health care, wire, and mail fraud because each patient listed in the indictment for those charges did not testify, there was no audio or video evidence of those patients, there was no description of Martinez’s treatment of those patients by government witnesses, and the names of those patients were not mentioned during the testimony of the expert witnesses. He also argues that the evidence was insufficient on the fraud counts based on nerve-block injections because the Government’s case at trial focused solely on Martinez’s prescription practices, not the nerve-block injections. In determining whether there is sufficient evidence to support a conviction, the question before us is whether, “after viewing the evidence in the light most favorable to the prosecution, any rational trier of fact could have found the essential elements of the crime beyond a reasonable doubt.” Jackson v. Virginia, 443 U.S. 307, 319 (1979) (emphasis omitted). In making this determination, we “reverse a judgment for insufficiency of evidence only if [the] judgment is not supported by substantial and competent evidence upon the record as a whole, [whether or not] the evidence is direct or wholly circumstantial.” United States v. Stone, 748 F.2d 361, 363 (6th Cir. 1984). Moreover, “circumstantial evidence alone can sustain a guilty verdict[, and it] need not remove every reasonable hypothesis except that of guilt.” United States v. Hughes, 505 F.3d 578, 592 (6th Cir. 2007) (emphasis omitted) (quoting Stone, 748 F.2d at 362). 1. Counts 38-58: Health Care Fraud in Violation of 18 U.S.C. § 1347 To obtain a conviction for health care fraud under 18 U.S.C. § 1347, the Government is required to prove beyond a reasonable doubt that Martinez: “(1) knowingly devised a scheme or artifice to defraud a health care benefit program in connection with the delivery of or payment for health care benefits, items, or services; (2) executed or attempted to Nos. 06-3882/4206 United States v. Martinez Page 14 1 execute this scheme or artifice to defraud; and (3) acted with intent to defraud.” Hunt, 521 F.3d at 645 (internal quotations omitted). After reviewing evidence adduced at trial in the light most favorable to the Government, we conclude that a rational jury could have found beyond a reasonable doubt that Martinez violated § 1347. First, we note that, contrary to Martinez’s argument, the lack of individualized patient testimony for each count in the indictment alone does not render the evidence before the court insufficient. See United States v. Clark, 26 F. App’x 422, 431 (6th Cir. 2001) (relying on expert testimony instead of patient testimony to establish health care fraud under § 1347). If expert testimony is offered in lieu of patient testimony, the expert testimony should be sufficiently specific to the patient, date, and services in the indictment, but the patients’ names need not be specifically mentioned during the expert’s testimony. Id.; cf. United States v. Tran Trong Cuong, 18 F.3d 1132, 1141 (4th Cir. 1994) (finding evidence insufficient to support a doctor’s conviction on eighty counts for drug distribution outside the usual course of medical practices and for other than legitimate medical purposes where the convictions were based on a medical expert’s summary report of thirty-three patient files that were not related to the patients listed in the eighty-count indictment). Accordingly, we must determine whether the evidence submitted is sufficient to support Martinez’s health care fraud conviction, even though the Government did not offer individualized patient testimony. We conclude that substantial and competent evidence supports the conclusion that Martinez executed a scheme to defraud a health care benefit program by the means alleged (the second element of § 1347). The jury heard evidence that between 1998 and 1 18 U.S.C. § 1347 is titled “Health care fraud,” and states in relevant part: Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice - -
(2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both. Nos. 06-3882/4206 United States v. Martinez Page 15 2004, Martinez obtained millions of dollars from Medicare, Medicaid, BWC, and private insurers by submitting fraudulent claims for office visits and injections. The Government presented the billing codes that Martinez submitted for reimbursement for each day listed in the indictment, the patients’ files, and testimony from Dr. Kennedy that Martinez could not have conducted the number of procedures and consultations for which he billed. The jury heard evidence that Martinez routinely saw more than sixty patients, and often more than 100 patients in a day. Additionally, the jury reviewed video and audio recordings that demonstrated the brief amount of time that Martinez was physically present with each patient and heard testimony that the billing codes submitted required a more thorough office visit than the recordings demonstrated. The jury also heard testimony that Martinez’s jabbing techniques could not have possibly served as legitimate injections. Moreover, Dr. Kennedy testified that Martinez’s prescription practices for controlled substances was outside the bounds of accepted medical practice. Last, the jury was presented with sufficient evidence to support an inference that Martinez was perpetuating a fraud when he gave injections with such frequency. This inference is supported by the testimony of Dr. Kennedy and Dr. Parran, who explained that the frequency of injections was so high as to endanger the health of the patients. Both physicians testified that the injections were performed as part of a “standard” rather than an “individualized” treatment plan. The doctors also testified that many of the injections for which Martinez billed were not performed, or, if performed, were not medically necessary. Taken together, a jury easily could have inferred from this evidence that the bills submitted were part of a scheme to defraud the medical benefit programs. See United States v. Canon, 141 F. App’x 398, 405 (6th Cir. 2005) (upholding doctor’s conviction under 18 U.S.C. § 1347 because government witness testified that patient records did not support the doctor’s use of billing codes and “a rational jury could infer a failure to perform from a failure to document”). Second, we conclude that there is sufficient evidence to support the jury’s determination that Martinez knowingly devised a fraud scheme (the first element of § 1347) and that Martinez acted with the intent to commit fraud (the third element of § 1347). Martinez’s records for each patient named in the indictment and the claims that Nos. 06-3882/4206 United States v. Martinez Page 16 Martinez submitted for reimbursement were admitted into evidence and available to the jury for review. Dr. Kennedy testified that he reviewed the bills Martinez submitted and his patient files, (JA 1266-68, 1274-78), and concluded that the billing was “not appropriate in any fashion” and that the procedures claimed in the billing were “not medically necessary in any way.” (J.A. 1359-60.) Considering the evidence that Martinez performed procedures and prescribed medication that expert witnesses deemed medically unnecessary, a rational jury could infer that Martinez knowingly devised a billing scheme with the intent to defraud. We, therefore, conclude that there is sufficient evidence to support Martinez’s conviction for health care fraud under 18 U.S.C. § 1347. 2. Counts 13-37: Mail and Wire Fraud in Violation of 18 U.S.C. §§ 1341 and 1343 18 U.S.C. § 1341 prohibits the use of the mail to execute a scheme to defraud.2 To convict Martinez of mail fraud under 18 U.S.C. § 1341, the Government was required to prove beyond a reasonable doubt: “(1) a scheme to defraud, and (2) [that Martinez caused] the mailing of a letter, etc., for the purpose of executing the scheme.” Pereira v. United States, 347 U.S. 1, 8 (1954); see also Bender v. Southland Corp., 749 F.2d 1205, 1215-16 (6th Cir. 1984). One “causes” the mails to be used where he or she “does an act with knowledge that the use of the mails will follow in the ordinary course of business, or where such use can reasonably be foreseen, even though not actually intended.” Pereira, 347 U.S. at 8-9. “The federal statute prohibiting mail fraud parallels section 1343.” United States v. Griffith, 17 F.3d 865, 874 (6th Cir. 1994) (citing 18 U.S.C. § 1343). Indeed, the elements of § 1341 and § 1343 are nearly identical. To obtain a conviction under § 1343, the Government must prove beyond a reasonable doubt: “(1) a scheme or artifice to defraud; (2) use of interstate wire communications in 2 18 U.S.C. § 1341, entitled “Frauds and swindles,” states in relevant part: Whoever, having devised or intending to devise any scheme or artifice to defraud, or for obtaining money or property by means of false or fraudulent pretenses, representations, or promises . . . for the purpose of executing such scheme or artifice or attempting so to do . . . knowingly causes to be delivered by mail or such carrier according to the direction thereon, or at the place at which it is directed to be delivered by the person to whom it is addressed, any such matter or thing, shall be fined under this title or imprisoned not more than 20 years, or both. Nos. 06-3882/4206 United States v. Martinez Page 17 furtherance of the scheme; and (3) intent to deprive a victim of money or property.”3 United States v. Daniel, 329 F.3d 480, 485 (6th Cir. 2003) (quoting United States v. Prince, 214 F.3d 740,747-48 (6th Cir. 2000)). Moreover, the first element of each section (scheme to defraud) parallels, in part, the first element of health care fraud under § 1347. See 18 U.S.C. § 1347. As we have already noted, the Government presented sufficient evidence from which a rational jury could find the first element (a scheme to defraud) and the third element (intent to defraud) of both mail and wire fraud. Thus, for purposes of determining sufficiency of the evidence, we need only determine whether evidence existed from which a rational jury could conclude that Martinez used the mail and wire communications for each of the specified underlying fraud counts. See 18 U.S.C. §§ 1341, 1343. We also note that Martinez does not challenge the sufficiency of the evidence as to the second element of each crime—that he caused the allegedly fraudulent bills to be mailed or transmitted by wire communications. As such, Martinez has forfeited any challenge to the sufficiency of the evidence for this element. United States v. Crozier, 259 F.3d 503, 517 (6th Cir. 2001) (citing United States v. Layne, 192 F.3d 556, 566 (6th Cir. 1999)) (noting that arguments not developed on appeal are deemed forfeited). Accordingly, we conclude that there is sufficient evidence for a jury to conclude that Martinez committed mail and wire fraud. 3 18 U.S.C. § 1343, entitled “Fraud by wire, radio, or television,” states in relevant part: Whoever, having devised or intending to devise any scheme or artifice to defraud, or for obtaining money or property by means of false or fraudulent pretenses, representations, or promises, transmits or causes to be transmitted by means of wire . . . in interstate or foreign commerce, any writings . . . for the purpose of executing such scheme or artifice shall be fined under this title or imprisoned not more than 20 years, or both. Id. Nos. 06-3882/4206 United States v. Martinez Page 18 3. Counts 59 and 60: Health Care Fraud Resulting in Death in Violation of 18 U.S.C. § 1347(2) Finally, Martinez appeals his conviction under 18 U.S.C. § 1347(2), which contains enhanced penalties in the event that a doctor’s health care fraud results in the death of a patient. Section 1347(2) states, in relevant part: “[I]f the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both.” As addressed above, there is sufficient evidence to support a rational jury’s conviction of Martinez for health care fraud under § 1347. At trial, the Government proceeded under the theory that Martinez’s prolonged fraudulent treatment, rather than any single treatment or dose, resulted in John Lancaster’s and Blair Knight’s deaths. Martinez, however, argues that the Government failed to show that a rational jury could find that he caused their deaths. Thus, the standard of causation required to show that such fraud “result[ed] in death” becomes important in determining whether there is sufficient evidence to support Martinez’s conviction as to these two counts. This is an issue of first impression in this Circuit.4
Section 1347 does not indicate the level of causation required to support application of its enhanced penalties, but other federal statutes elevate punishment when certain willful crimes “result in death.” In particular, 18 U.S.C. § 242 allows for a life sentence if death results from certain intentional civil rights violations. In United States v. Marler, the First Circuit determinated that § 242’s requirement for enhanced punishment is met when the defendant’s willful violation of the statute is a “proximate cause” of the victim’s death, concluding that proximate cause can be demonstrated where death was the “natural and foreseeable” result of the defendant’s conduct. 756 F.2d 206, 215-16 (1st Cir. 1985); see also United States v. Woodlee, 136 F.3d 1399, 4 Although we are the first circuit court to consider what level of causation is required under the statute, the Eleventh Circuit has considered whether evidence sufficiently supported a conviction for health care fraud “[resulting] in bodily injury or death” under 18 U.S.C. § 1347, see United States v. Merrill, 513 F.3d 1293, 1298-99 (11th Cir. 2008), and several district courts have examined whether allegations were sufficient to support an indictment under that provision. See United States v. Salko, No. 1:07-CR-0286, 2008 U.S. Dist. LEXIS 65211, at  (M.D. Pa. Aug. 26, 2008); United States v. Mermelstein, 487 F. Supp. 2d 242 (E.D.N.Y. 2007). However, none of those courts has specifically construed the meaning of the “result[ed] in death” language. Nos. 06-3882/4206 United States v. Martinez Page 19 1405 (10th Cir. 1998) (holding that “the bodily injury element of the felony crime is satisfied if injury was a foreseeable result of the” defendants’ violation of 18 U.S.C. § 254(b)); United States v. Harris, 701 F.2d 1095, 1101 (4th Cir. 1983) (holding that the “if death results” language of 18 U.S.C. § 241 requires only that death is foreseeable and naturally results from violating the statute); United States v. Guillette, 547 F.2d 743, 749 (2d Cir. 1976) (holding that life imprisonment may be imposed if death results from violations of 18 U.S.C. § 241 when the defendant’s violation of that statute is a proximate cause of the victim’s death). Although we have not interpreted the “results in death” language of § 242, in United States v. Wiegand, we interpreted what level of causation is required to show “if bodily injury results” under 42 U.S.C. § 3631. No. 93-1735, 1994 U.S. App. Lexis 37209, at  (6th Cir. Dec. 22, 1994). Section 3631 imposes a maximum one-year sentence for interfering with an individual’s housing rights “because of [the individual’s] race.” 42 U.S.C. § 3631(a). If, however, bodily injury results, the offense becomes a felony and is punishable for up to ten years in prison. Id. We upheld the enhanced punishment because the bodily injury that occurred was the “natural and foreseeable” result of the defendant’s violation of the statute. In coming to this conclusion, we explained “[a] fundamental principle of criminal law”: “[A] person is held responsible for all consequences proximately caused by his criminal conduct. Thus, where events are foreseeable and naturally result from one’s criminal conduct, the chain of legal causation is considered unbroken . . . .” Wiegand, 1994 U.S. App. Lexis 37209, at  (internal quotation omitted). Additionally, in determining that proximate cause was the appropriate causation requirement under 18 U.S.C. § 242, the First Circuit in Marler reasoned that “[w]hen the Congress provided that [a violation] resulting in death may be punished by life imprisonment, we must consider it to have been fully cognizant of the principles of legal causation.” 756 F.2d at 216. The same is true here. Congress was aware of principles of legal causation when it determined that a health care fraud “violation [that] results in death” warrants an enhanced penalty. See 18 U.S.C. § 1347. We also note that the parties do not challenge the district court’s determination that proximate cause is the Nos. 06-3882/4206 United States v. Martinez Page 20 appropriate standard of causation, and the jury instructions required the jury to find that Martinez was the proximate cause of the death of the two patients in order to convict him of health care fraud resulting in death.5 We therefore conclude that proximate cause is the appropriate standard to apply in determining whether a health care fraud violation “results in death.” b. Sufficiency of the evidence to convict Martinez of health care fraud “resulting in death” Martinez argues that there is insufficient evidence to conclude that he proximately caused the deaths of Lancaster and Knight. As we have already determined, the evidence sufficiently demonstrated that Martinez committed fraud when he treated patients by hurriedly giving them injections and prescriptions rather than taking sufficient time to provide his patients with individualized care; the issue of whether Martinez was the proximate cause of his two patients’ deaths is a closer question. Our decision, however, is guided by the deference we must give to the jury’s verdict. We must review the relevant evidence in the light most favorable to the Government and must affirm Martinez’s conviction if any rational trier of fact could find that he was the proximate cause of Lancaster’s and Knight’s deaths. Jackson, 443 U.S. at 319. “This standard is a great obstacle to overcome, and presents the appellant in a criminal case with a very heavy burden.” United States v. Matthews, 298 F. App’x 460, 464 (6th Cir. 2008) (internal citations omitted). Thus, in undertaking our review of the jury’s finding that Martinez was the proximate cause of the two patients’ deaths, we cannot “substitute [our] judgment for that of the jury.” Id. 5 During the trial, the jury was instructed that to convict Martinez of health care fraud resulting in death, it had to find that Martinez’s fraud was the “proximate or direct cause” of the two patients’ deaths. According to the instructions, “proximate or direct cause exists where the acts of the Defendant in committing healthcare fraud in a natural and continuous sequence directly produces the deaths and without which they would not have occurred.” (JA 807.) The court also explained that Martinez is not responsible for the deaths of Lancaster and Knight if Martinez’s alleged commission of health care fraud was a remote cause of their deaths, i.e., if “the result could not have been reasonably foreseen or anticipated as being the likely cause of the deaths.” (JA 807-08.) The jury was further instructed that proximate cause does not exist “when another’s act, which could not have been reasonably foreseen and is fully independent of [Martinez’s] alleged healthcare fraud, intervenes and completely breaks the effect of [Martinez’s] conduct.” (JA 808.) Nos. 06-3882/4206 United States v. Martinez Page 21 Our decision is also guided by the principles of proximate cause. “The concept of proximate cause incorporates the notion that an accused may be charged with a criminal offense even though his acts were not the immediate cause of the victim’s death or injury.” Guillette, 547 F.2d at 749. “In many situations giving rise to criminal liability,” the harm “is not directly caused by the acts of the defendant but rather results from intervening forces or events.” Id. “Where such intervening events are foreseeable and naturally result from [the defendant]’s criminal conduct,” the defendant is “criminally responsible for the resulting harm.” Id.; see also Hoopengarner v. United States, 270 F.2d 465, 469 (6th Cir. 1959) (holding defendant culpable for the “natural and probable consequence[]” of his conduct). Therefore, even if Martinez did not intend for his two patients to die, he can be held responsible for their deaths if there was sufficient evidence that it “reasonably might or should have been foreseen . . . that [his fraudulent conduct] would be likely to create a situation which would expose another to the danger of . . . death.” Id.; see also Harris, 701 F.2d at 1102 (holding that “if death results” requirement under § 241 satisfied because death was “a foreseeable and natural result” of defendant’s actions).
The evidence presented is sufficient for a rational jury to conclude that Lancaster’s death was a reasonably foreseeable consequence of Martinez’s fraudulent treatment. The evidence demonstrates that Martinez treated Lancaster nearly every week from January 1999 until September 2001, providing him with excessive injections and prescriptions, inadequately monitoring him, and failing to provide him with individualized care. During this period of time, Lancaster’s health deteriorated from that of a relatively healthy and well-adjusted, albeit injured, individual to a moody, abusive, and angry individual who no longer worked. There was sufficient evidence for a rational jury to infer that Martinez’s treatment of Lancaster enabled and exacerbated Lancaster’s addiction to controlled substances. Moreover, Lancaster’s wife, Karen Lancaster, testified that she told Martinez that Lancaster had become addicted to drugs and that Martinez responded by becoming “defensive and very angry.” (JA 2380-83.) Additionally, notes in Lancaster’s file indicated that Martinez’s staff was aware that Nos. 06-3882/4206 United States v. Martinez Page 22 Lancaster was at risk of becoming an addict and that he had been dismissed as a patient by other doctors because of his dependency on prescription drugs. One note in Lancaster’s file indicated that he had either used or sold heroin, OxyContin, and Valium, and another note on a patient sign-in sheet identified Lancaster as an addict. Even Martinez’s own expert, Dr. Stinson, testified that such signals would lead any “reasonable” doctor to cease providing drugs to Lancaster. Despite the warning signs, Martinez did not alter his treatment of Lancaster––including the last time Martinez treated Lancaster. Lancaster’s wife testified that on September 4, 2001, Lancaster had recently been released from jail, where he had not taken any pain medication. She also testified that her husband was very weak and had lost weight. At Lancaster’s last appointment with Martinez on September 5, 2001, Lancaster was shaky, loud, and complaining of severe pain because he was suffering withdrawal symptoms. Martinez provided Lancaster with prescriptions for Kadian, Vicodin, and Valium, all of which Lancaster filled on that day. On the day before Lancaster’s death, September 12, 2001, Martinez billed insurance carriers for twelve injections to Lancaster, although it is not clear that the billed-for injections were actually given on September 5, 2001. Additionally, Martinez submitted the standard report to BWC for payment indicating that Lancaster had no complications from the injections, made a good recovery, and was discharged in “good condition.” The record demonstrates, however, that Lancaster was in anything but “good condition.” Records of Lancaster’s office visit show that Lancaster was loud and shaky, that Martinez may have slapped Lancaster to calm him down, and that Lancaster took a four-hour nap on the examination table following the injections. Less than thirty-six hours after his appointment with Martinez, Lancaster was found unconscious, and he died less than one week later from aspiration pneumonia caused by a drug overdose. Lancaster’s urinary drug screen tested positive for opiates, which include Kadian and Vicodin; and benzodiazepines, which include Valium and cocaine. There is also evidence that Lancaster had ingested heroin and cocaine, but tests were inconclusive as to what drugs actually killed him. However, hospital records indicate that, on the afternoon before he was admitted, Lancaster told his wife that he took three Kadian pills Nos. 06-3882/4206 United States v. Martinez Page 23 at once. Records also show that Lancaster filled his final Kadian prescription from Martinez, and Lancaster had not received a Kadian prescription from any other physician for two months before his death. In addition, Dr. Kennedy testified that Martinez’s entire course of treatment of Lancaster was a “very strong factor” in Lancaster’s death, and that at Lancaster’s last appointment, Martinez “sent him home with medications . . . that contributed directly to his death.” (JA 1432-35.) Dr. Parran likewise concluded that Martinez’s prescriptions were outside the bounds of medical practice and given for no legitimate purpose. Viewing the evidence in the light most favorable to the Government, a rational jury could have concluded that Lancaster’s death was a foreseeable result of Martinez’s conduct. Martinez over-prescribed controlled substances that led to Lancaster’s addiction to narcotics, and Martinez continued to perform unnecessary injections and prescribe harmful medications despite the presence of the clear “red flags” of escalating addiction. A rational jury could have found that the evidence demonstrates the fraud for which Martinez was convicted—providing poor, inattentive treatment while billing for quality treatment and excessive, highly-reimbursed nerve-block injections and prescriptions—proximately caused Lancaster’s death. Thus, there is sufficient evidence for the jury to conclude that Lancaster’s death by overdose was a reasonably foreseeable result of Martinez’s conduct. Cf. Merrill, 513 F.3d at 1298-99 (holding that although patients had other illegal substances in their systems when they died, sufficient evidence existed for a reasonable jury to conclude that the physician’s fraudulent prescriptions caused their deaths because the additional drugs found in their system were the same type as those prescribed by the physician). In an attempt to break the chain of causation, Martinez argues that Lancaster’s use of illegal narcotics constitutes an intervening cause relieving Martinez of criminal culpability. This argument fails. “An intervening act is a coincidence when the defendant’s act merely put the victim at a certain place at a certain time, and because the victim was so located it was possible for him to be acted upon by the intervening cause.” Wayne R. LaFave, 1 Substantive Crim. L. § 6.4 (f)(3) (2d ed. 2008) (emphasis omitted). But, “an intervening act may be said to be a response to the prior actions of the Nos. 06-3882/4206 United States v. Martinez Page 24 defendant when it involves reaction to the conditions created by the defendant.” Id. (emphasis omitted); Guillette, 547 F.2d at 749 (“The concept of proximate cause incorporates the notion that an accused may be charged with a criminal offense even though his acts were not the immediate cause of the victim’s death or injury.”). Accordingly, where “intervening events are foreseeable and naturally result” from a defendant’s criminal conduct, “the chain of legal causation [is] unbroken” and the law “holds the [defendant] criminally responsible for the resulting harm.” Guillette, 547 F.2d at 749. Because “the perimeters of legal cause are more closely drawn when the intervening cause was a matter of coincidence rather than response,” an unforeseeable coincidence will break the chain of legal cause, but a response will only do so if it is abnormal. LaFave, 1 Subst. Crim. § 6.4(f)(3). Here, Martinez was not convicted of being the immediate cause of his patients’ deaths but of fraudulently performing unnecessary medical services that led to his patients’ deaths. The jury could have concluded that Martinez’s treatment enabled and exacerbated Lancaster’s addiction, and that, given that addiction, the overdose was a natural and reasonably foreseeable result. See LaFave, 1 Subst. Crim. § 6.4(h) (noting that with respect to felony murder, “self-inflicted harms attributable to the victim’s weakened condition[] are quite normal and thus do not break the causal chain”). Moreover, the jury was given an intervening-cause instruction. They were instructed that they could not convict Martinez if they found that the cause of the two patients’ deaths was reasonably foreseen and independent of Martinez’s alleged health care fraud. We must presume that the jury followed the instructions unless we have evidence to the contrary. See Washington v. Hofbauer, 228 F.3d 689, 706 (6th Cir. 2000). Because a rational jury could have found that the addiction and overdose were sufficiently linked, we must defer to the jury’s reasonable judgment that the chain of legal causation was not broken. Our deferential standard of review requires that we not displace the jury’s verdict when Lancaster’s actions as an addict cannot to be said to break the chain of proximate causation. See Molton v. City of Cleveland, 839 F.2d 240, 248 (6th Cir. 1988) (holding that suicide of prisoner in police custody was a foreseeable consequence under Nos. 06-3882/4206 United States v. Martinez Page 25 the circumstances and, therefore, not an independent intervening cause breaking the chain of proximate causation).
As with Lancaster, there is no evidence that a prescription written by Martinez directly caused Knight’s death, but there is sufficient circumstantial evidence to allow a rational jury to conclude that Martinez proximately caused his death. Before his death, Knight was Martinez’s patient for sixteen months, and evidence supports a conclusion that Martinez fraudulently treated Knight in a manner similar to that of other patients. Evidence at trial demonstrated that, over the course of Knight’s treatment by Martinez, Knight’s health deteriorated such that he was bloated, unresponsive, and immobile. As with Lancaster, there were “red flags” that Martinez’s treatment was enabling and exacerbating Knight’s addiction to controlled substances. There were notes in Knight’s charts indicating that Martinez’s staff was aware of Knight’s addiction and that Knight’s treatment was harming him, including notes that his speech was “slurred and slow,” that Knight had trouble walking due to the lack of feeling in his leg, and that he was failing to follow the doctor’s prescribing orders. A January 3, 2001, letter in Knight’s patient file indicated that Knight was being treated at a drug rehabilitation facility. Moreover, an August 29, 2000, note in Knight’s patient chart stated that Knight was taking “double the number” of OxyContin pills that Martinez prescribed, and that his speech was “slurred and slow”––indicating overuse of the drug. (JA 1446-47, 3625.) And, as with Lancaster and Martinez’s other patients, there is no indication that Martinez provided individualized treatment or appropriately responded to these red flags but, instead, continued to provide Knight with prescriptions and injections. During the two weeks preceding Knight’s death, he twice visited Martinez in extreme pain. Knight was so bloated that he could not wear socks or shoes and was covered in a red rash. Nonetheless, Martinez’s office notes show that Knight received the “standard treatment,” and the notes contain the same generic statements indicating that all was going well. There is no evidence that Martinez altered his treatment of Knight even though these were indications of drug misuse. Knight died of a drug Nos. 06-3882/4206 United States v. Martinez Page 26 overdose on the same day as his last visit with Martinez. Toxicology reports indicate that Knight overdosed on OxyContin pills from an unknown source, as well as hydrocodone and Valium. The jury heard evidence that when Knight was transported to the hospital, he had green-colored medicine in his mouth and nose, and that OxyContin tablets are green or bluish green. During that last office visit, Martinez prescribed OxyContin and Endodan, and pharmacy records show that Martinez was the only doctor who prescribed OxyContin to Knight shortly before his death. There is no definitive evidence that Martinez prescribed the drugs in Knight’s system at the time of his death. Nonetheless, there is sufficient evidence that Martinez’s overall course of treatment proximately caused Knight’s death. Dr. Kennedy testified that Martinez’s entire course of treatment of Knight “contributed largely” to Knight’s death. The jury heard evidence that Knight became addicted to narcotics as a result of Martinez’s fraudulent prescriptions and injections. Dr. Kennedy suggested that Martinez should have monitored Knight’s addiction and provided him with medication only under the supervision of an addiction specialist. He also testified that Martinez continued to feed Knight’s addiction in order to get Knight to “come in and get [billable] procedures.” (JA 1457.) Similarly, Dr. Parran testified that “any reasonable physician should [have known] that this patient has an addiction problem” and should have known that continued prescriptions would create a risk of overdose. (JA 2118-19.) Based on this evidence, a reasonable jury could have inferred that Martinez furthered Knight’s addiction to advance his fraudulent billing scheme and that Knight’s subsequent misuse of prescribed substances was a foreseeable result of that addiction. Viewing the evidence in the light most favorable to the Government, a rational jury could have concluded that Knight’s overdose was the reasonably foreseeable result of Martinez’s conduct.