Opinion ID: 3012591
Heading Depth: 1
Heading Rank: 3

Heading: Constructive Amendment to Counts 18-29

Text: Syme contends that the District Court erred by instructing the jury on the Pennsylvania rate theory of fraud for counts 18-29, even though the indictment does not allege the theory in those counts. Syme did not raise this argument in the District Court and we therefore apply the plain error standard of review. See Fed. R. Crim. P. 52(b); see also supra note 4. 23
Amending the Indictment? A constructive amendment occurs where a defendant is deprived of his substantial right to be tried only on charges presented in an indictment returned by a grand jury. United States v. Miller, 471 U.S. 130, 140 (1985) (quoting Stirone v. United States, 361 U.S. 212, 217 (1960)) (internal quotation marks omitted). A constructive amendment to the indictment constitutes a per se violation of the fifth amendment's grand jury clause. United States v. Castro, 776 F.2d 1118, 1121-22 (3d Cir. 1985). In their text, counts 18-29 of the superseding indictment charge Syme under three alternative theories of fraud: (1) that he submitted Medicare forms indicating that ambulance trips were medically necessary when they were not (medical necessity); (2) that he falsified the description of the treatment, service, or destination of the ambulance trip (treatment, service, or destination); and (3) that he submitted duplicate bills for single ambulance trips, one using a Delaware ambulance provider number, and one using a Pennsylvania ambulance provider number (duplicate billing). The text of the indictment for counts 18-29 does not specifically charge Syme under the Pennsylvania rate theory of fraud. However, a chart accompanying these counts, which lists the various theories supporting each charge, does list the Pennsylvania rate theory in the sections for counts 19, 21, 23, 24, 27, and 29. The chart appeared in the superseding indictment as follows: 24 ID: Graphic of Counts XVIII through XXIX 25 Although the Pennsylvania rate theory was neither mentioned in the text of the indictment, nor listed in the accompanying chart for several of the counts in the 18-29 group, the District Court instructed the jury that it could convict on all of the counts in this group based on the Pennsylvania rate theory. In its jury instructions, the Court stated: The next criminal act that has been charged is false claims. Counts 10 through 29 of the indictment charge that the defendants did make and present and caused to be made and presented to the Health Care Financing Administration, . . . claims for services provided to Medicare and/or Medicaid patients, the defendants knowing the claims to be false and fraudulent, which is prohibited by federal law. The indictment charges that defendants falsely submitted bills that were not medically necessary and were not for covered services, and that bills were improperly submitted at the higher Pennsylvania rate . (emphasis added). The District Court repeated its erroneous instruction on the Pennsylvania rate theory in its response to the following question from the deliberating jury (which references the abbreviations for the government's different theories of fraud in the case, explained in the margin)6: First let me read the question. The question says: Must we find all elements of the false statement proven? Then, there is parentheses, (i.e., PA, MN, _________________________________________________________________ 6. The superseding indictment defines the abbreviations that the prosecution and the jury used to refer to the different theories of fraud presented. PA refers to the scheme whereby Syme would submit bills . . . for transportation services billed at the Pennsylvania rate instead of the Delaware or Maryland rate. MN means a scheme in which the defendants intentionally falsely represent[ed] that the [ambulance] transportation was medically necessary. Dest. refers to the practice of intentionally . . . send[ing] false and misleading information concerning the destination of the ambulance trip. And finally, Treat. means intentionally transmit[ting] false and misleading information concerning the . . . reason for the transportation, i.e., the medical treatment sought. 26 treat., dest.), close parens, to render a verdict on each count, or would only one element suffice? The first part of my answer is this: In your deliberations, to render a verdict on the false statement counts, you must find that the government has proven beyond a reasonable doubt each element of the crime of making a false statement. And in the instructions I provided you, I gave you the law of what the elements are for the crime of false statement. . . . . Now, in the question, the second part of my answer is, when you refer to items such as PA, MN, Treat. and Dest. as elements, I interpret your question to mean entries on the statements. In order to find on an entry, you would only have to find one of the entries was proven to be false beyond a reasonable doubt, as long as all the other elements were proven to your satisfaction beyond a reasonable doubt. So I answer you in two parts. Using the word element, all elements of the crime have to be proven beyond a reasonable doubt. One of the elements is there has to be a false entry. It only has to be proven beyond a reasonable doubt that one of the entries entered meets all of the elements. The government concedes that the District Court committed error in its instructions to the jury on Counts 18, 20, 22, 25, 26 and 28 because the sections of the indictment corresponding to these counts do not reference the Pennsylvania rate theory. As to the remaining counts in the 18-29 group, the government argues that the District Court did not constructively amend the indictment because the Pennsylvania rate theory was alleged in the indictment for these counts. The government relies on the chart that was included in the indictment. See supra at 25. The chart lists the various charges, and the theories on which each is based. Each horizontal row of the chart represents a different count of the indictment. Each vertical column in the chart has a heading telling which information corresponds to which count (e.g., Billing Date or Money Billed). One heading labeled False State. refers to the 27 category of statement or statements that the count alleges Syme to have falsely made on his reimbursement forms. This box contains abbreviations that correspond with the different categories of information that the government charged Syme with falsifying. The abbreviation PA appears in the False State. column for the rows corresponding to counts 19, 21, 23, 24, 27, and 29. As we explained above, see supra note 6, PA is defined earlier in the indictment to mean submit[ting] bills . . . for transportation services billed at the Pennsylvania rate instead of the Delaware or Maryland rate. Therefore, argues the government, Syme was effectively indicted in these counts on the Pennsylvania rate theory and the District Court therefore did not amend these counts in its jury instructions or its answer to the jury's question. Syme responds that including the termPA in the chart corresponding to the counts in question was alone insufficient when the theory was not also described in the text of the indictment that corresponded to these counts. It is particularly confusing, argues Syme, because when the same `PA' abbreviation was used in a chart pertaining to the other fraud and false claims counts, it was used together with charging language. Although the indictment is below the level of clarity to which prosecutors should aspire, we agree with the government that the chart sufficiently alleges the Pennsylvania rate theory for counts 19, 21, 23, 24, 27, and 29 for the purpose of determining whether there has been a constructive amendment to the indictment. There is nothing impermissible about setting out allegations in an indictment by a chart as long as the terms used in the chart are clearly defined, as they were here. Cf. United States v. Heath, 122 F.3d 682, 684 (8th Cir. 1997) (holding that it was not error for a sentencing court toconsider all of the acts charged in the indictment including a chart that was incorporated by reference in one of the counts). Indeed, Federal Rule of Evidence 1006 recommends the value of presenting evidence to a jury in the form of a chart when doing so would increase the clarity of presentation. In sum, while the use of charts in this indictment is somewhat inconsistent internally, we find that the chart 28 accompanying counts 19, 21, 23, 24, 27, and 29 makes it sufficiently clear that those counts alleged the Pennsylvania rate theory. Therefore, we find that the District Court erred by constructively amending the indictment only as to counts 18, 20, 22, 25, 26 and 28.
The government concedes that the District Court's error was clear with respect to counts 18, 20, 22, 25, 26, and 28. Cases from the Supreme Court and this court hold that it violates the Grand Jury Clause of the Fifth Amendment when a court instructs a jury on a ground for conviction that is not fully contained in the indictment. See Miller, 471 U.S. at 140; Castro, 776 F.2d at 1121-22. Nowhere in counts 18, 20, 22, 25, 26, or 28, including the chart, does the indictment allege the Pennsylvania rate theory. Therefore, we agree that it was clear error for the District Court to instruct the jury on the Pennsylvania rate theory for those counts. C. Did the Error Affect Syme's Substantial Rights? Under plain error review, a defendant must also show that the clear error  `affected [the defendant's] substantial rights.'  United States v. Nappi, 243 F.3d 758, 762 (3d Cir. 2001) (quoting United States v. Olano, 507 U.S. 725, 734 (1993)). In most cases, the language about affecting substantial rights `means that the error must have been prejudicial,' that is, `[i]t must have affected the outcome of the district court proceedings.'  United States v. Stevens, 223 F.3d 239, 242 (3d Cir. 2000) (quoting Olano , 507 U.S. at 734). Syme was found not guilty on counts 18, 20, 22, 26, and 28. Therefore, the constructive amendment of these counts obviously did not affect his substantial rights. That leaves only the question whether the constructive amendment of count 25 affected Syme's substantial rights. Syme does not attempt to demonstrate that the constructive amendment to count 25 was prejudicial. Instead, he submits that our holding in United States v. Castro, 776 F.2d 1118, 1121-22 (3d Cir. 1985), that a constructive amendment is per se reversible error, compels 29 us to find that a constructive amendment per se affects a defendant's substantial rights under plain error analysis. The government argues the opposite, maintaining that under plain error review, it is the defendant's burden to show that the constructive amendment was prejudicial. Neither Castro nor United States v. Somers, 496 F.2d 723 (3d Cir. 1974), the Third Circuit case on which Castro relies for the proposition that a constructive amendment is per se reversible, specify whether the per se rule that they cite applies under both harmless error and plain error review. Stirone v. United States, 361 U.S. 212 (1960), the U.S. Supreme Court opinion that both Castro and Somers cite as authority to support the per se rule, reviewed a constructive amendment to which the defendant raised an objection in the district court, and thus does not necessarily extend the per se rule to the plain error context. See id. at 214. However, even if the general statements from Castro and Somers must be read to extend to the plain error context, it is uncertain whether this application of the per se rule has survived Olano, which recognized broader discretion for appellate courts exercising plain error review. See United States v. Dipento, 242 F.3d 1090, 1095 (9th Cir. 2001) (noting that it is uncertain whether the Ninth Circuit's per se reversal rule for constructive amendments under plain error review has survived Olano, but declining to decide). Several courts of appeals have considered the question whether a constructive amendment is per se reversible under the plain error standard, but the circuits are divided and the resulting law is checkered, as explained in the margin.7 However, the question whether the per se reversal _________________________________________________________________ 7. The Fourth Circuit, sitting en banc, has held that because a constructive amendment is per se error in the harmless error context, it also per se satisfies the affects substantial rights prong of the plain error test. See United States v. Floresca, 38 F.3d 706, 714 (4th Cir. 1994) (en banc). In the Ninth Circuit, it was established . . .[prior to Olano] that a constructive amendment required reversal, even under plain error review. United States v. Dipento, 242 F.3d 1090, 1095 (9th Cir. 2001). The Ninth Circuit has twice faced the question whether this rule has 30 rule of Castro and Somers applies in the context of plain error review appears to be one of first impression for us. As noted above, Olano stated that in order for an error to affect substantial rights under the plain error test, the defendant usually must show that the error was prejudicial, that is that it affected the outcome of the district court proceedings. 507 U.S. at 734. However, as we recently recognized in United States v. Adams , 252 F.3d 276 (3d Cir. 2001), the Supreme Court has cautioned that some errors to which no objection was made should be `presumed prejudicial' if the defendant cannot make a _________________________________________________________________ survived Olano, but declined to decide it, because it found that the error was prejudicial, and thus that it satisfied the plain error test. See id.; United States v. Shipsey, 190 F.3d 1081, 1087 (9th Cir. 1999). The Seventh Circuit recently purported to decline to reach the question whether a constructive amendment is per se reversible in the plain error context, but in an earlier case it seems to have reached the question and concluded that a defendant must show prejudice to succeed in a plain error challenge to a constructive amendment. Compare United States v. Cusimano, 148 F.3d 824, 828 n.3 (7th Cir. 1998) (noting that the court need not reach the issue of whether constructive amendments of indictments are always reversible because we conclude no amendment occurred), with United States v. Remsza, 77 F.3d 1039, 1044 (7th Cir. 1996) (applying the plain error framework's prejudice test to a constructive amendment and declining to reverse the conviction because the defendant suffered no prejudice). The D.C. Circuit and Second Circuit have both, after Olano, acknowledged that constructive amendments are per se reversible under harmless error review, but have nevertheless placed the burden on the defendant to show that the constructive amendment was prejudicial under plain error analysis. See United States v. Lawton, 995 F.2d 290, 294 (D.C. Cir. 1993); United States v. Vebeliunas, 1996 U.S. App. LEXIS 8727, at  (2d Cir. Feb. 21, 1996) (deciding, based on defendant's concession, that he could prevail under the plain error standard only by demonstrating that he was prejudiced). While the Fifth Circuit maintains a per se reversal rule for constructive amendments in the harmless error context, it has not addressed whether the same rule applies under plain error review because, citing concerns about defendant sandbagging, it concluded that it would exercise its discretion not to reverse a conviction even if all four prongs of the plain error test were met. See United States v. Reyes, 102 F.3d 1361, 1365 (5th Cir. 1996). 31 specific showing of prejudice. Id. at 285 (quoting Olano, 507 U.S. at 735). We also noted that under Olano , there may be a special category of forfeited errors that can be corrected `regardless of their effect on the outcome,'  and stated our assumption that this category is coextensive with the category of structural constitutional errors. Id. at 285 & n.6 (quoting Olano, 507 U.S. at 735). We concluded that Olano dictates that when a defendant fails to object[,] . . . his claim on appeal is reviewed for plain error -- which requires the defendant to make a specific showing of prejudice, unless he can show that the error should be presumed prejudicial, or that the error belongs in a special category of errors that should be corrected regardless of prejudice (i.e., the category of structural errors). Id. at 285. Adams addressed a denial of the right of allocution (i.e., the right of a criminal defendant to make a statement prior to sentencing). Adams did not reach the issue whether the denial of the right of allocution constituted structural error; rather it held that it fell into the other category of errors that should be presumed prejudicial. The question in this case, therefore, is whether constructive amendments fall into either of the two exceptions to the general rule that a defendant must demonstrate prejudice under plain error review. We turn first to the question whether constructive amendments fall into Olano's category ofthose errors that should be presumed prejudicial if the defendant cannot make a specific showing of prejudice. Olano , 507 U.S. at 735. In Adams, we found that the denial of a defendant's constitutional right of allocution falls within Olano's category of errors that should be presumed prejudicial in the plain error context. 252 F.3d at 287 (quoting Olano, 507 U.S. at 735) (internal quotation marks omitted). We noted that [g]iven the nature of the right[of allocution] and the difficulty of proving prejudice from its violation, we conclude that we should presume prejudice when a defendant shows a violation of the right and the opportunity for such a violation to have played a role in the district court's sentencing decision. Id. at 287. Like a denial of the right of allocution, a constructive amendment also violates a basic right of criminal 32 defendants, the grand jury guarantee of the Fifth Amendment. We follow the holding of Adams that some serious errors should be presumed prejudicial in the plain error context even if they do not constitute structural errors and find that constructive amendments fall into that category.8 Similar to the plight of a defendant who is denied the right of allocution, it is very difficult for a defendant to prove prejudice resulting from most constructive amendments to an indictment. In the present case, for example, it is nearly impossible for Syme to demonstrate that he was convicted on count 25 based on the Pennsylvania rate theory, rather than on one of the other theories of guilt pleaded in that count (i.e., that the constructive amendment altered the outcome on that count), even though there is a substantial possibility that he was convicted based on the Pennsylvania rate theory. As Syme points out, the District Court identified the Pennsylvania rate theory as the crux of the government's case. Therefore, we will apply in the plain error context a rebuttable presumption that constructive amendments are prejudicial (and thus that they satisfy the third prong of plain error review).9 _________________________________________________________________ 8. We note that our holding today is narrower than the rule that Adams applied because constructive amendments are constitutional errors that are of sufficient magnitude that they cannot be dismissed as harmless when a defendant objects to them in the district court. See Stirone, 361 U.S. at 217; Castro, 776 F.2d at 1121-22. By contrast, the right of allocution is not grounded in the Constitution. See Adams, 252 F.3d at 288. 9. We recognize that the presumption that we apply, like any exception to the general rule that the burden is on the defendant to demonstrate all of the prongs of the plain error test, may increase the likelihood of defendants sandbagging, i.e., failing to object to an error at the trial level in order to keep an issue for appeal as insurance in the event they are convicted. The Fifth Circuit cited its concerns about sandbagging as the reason for its refusal to notice plain error in the constructive amendment context. See Reyes, 102 F.3d at 1365. There are, however, two reasons why the potential instances of sandbagging arising from the presumption that we apply today will be limited. First, constructive amendments are a narrowly defined category of errors, which arise relatively infrequently. The presumption of prejudice under plain error analysis does not extend to the more frequently encountered category of 33 Applying the rule that constructive amendments are presumptively prejudicial under plain error review to the present case, we must determine whether the government has effectively rebutted the presumption that the constructive amendment was prejudicial. The government argues that the pattern of counts on which the jury convicted Syme reveals that it did not rely on the District Court's erroneous instructions, and that Syme was therefore not prejudiced by the constructive amendment. The jury convicted Syme on all of the counts in the 18-29 range in which the Pennsylvania rate theory was alleged in the chart accompanying the indictment but found him not guilty on all but one of the counts in which the Pennsylvania rate theory was not alleged. This pattern holds for all of the counts in this range except for count 25, in which the Pennsylvania rate theory was not alleged, but on which the jury convicted Syme. Thus, the government contends that the jury actually relied on the chart accompanying the indictment rather than the District Court's instructions and that Syme therefore could not have been prejudiced by the erroneous jury instructions. We find this argument unconvincing. We do not believe that the pattern of convictions is sufficient to support the conclusion that the government urges us to draw about the jury's motivations, i.e., that it relied on the chart and ignored the Court's instructions. As a rule, we presume the opposite -- that the jury follows a district court's _________________________________________________________________ variances from an indictment, which may be dismissed as harmless even when properly objected to at trial. See, e.g. , Castro, 776 F.2d at 1121 & n.1 (distinguishing constructive amendments from variances). Second, even with a presumption of prejudice in plain error analysis of constructive amendments, defendants who may be considering a sandbagging strategy still risk that an appellate court will exercise its discretion to refuse to notice plain error if the defendant fails to object to the error at the trial level. See Fed. R. Crim. P. 52(b) (Plain errors or defects affecting substantial rights may be noticed although they were not brought to the attention of the court.) (emphasis added); see also Olano, 507 U.S. at 732 (noting that appellate courts are not required to notice plain error, but may do so at their discretion). Appellate courts will be particularly reluctant to notice a constructive amendment as plain error if they suspect that the defendant was sandbagging. 34 instructions. See, e.g., Jermyn v. Horn , 266 F.3d 257, 312 (3d Cir. 2001). We therefore conclude that the government has not rebutted the presumption that the constructive amendment was prejudicial. Applying a presumption of prejudice to our plain error review of this constructive amendment, we conclude that the constructive amendment to count 25 affected Syme's substantial rights.10 Leaving this error uncorrected would seriously affect the fairness and integrity of the proceeding. See Olano, 507 U.S. at 736. We will therefore exercise our discretion to vacate Syme's conviction on count 25 of the superseding indictment and remand for a new trial on that count. D. Was the Evidence Presented Sufficient for the Jury to Convict Syme Based on the Medical Necessity Theory of Fraud for Count 25? Syme challenges the medical necessity theory of fraud _________________________________________________________________ 10. Because we hold that constructive amendments are presumptively prejudicial under plain error review, and that the government cannot rebut that presumption in this case, we need not address the question whether constructive amendments are structural errors (in which case we assume they would constitute per se reversible error even under plain error review). We note, however, that it is doubtful that constructive amendments are structural errors as the Supreme Court has defined that category. In its two most recent structural error cases, the Court listed the categories of errors that it has found to be structural. See Johnson v. United States, 520 U.S. 461, 468 (1997) (noting that the Court has found structural errors only in a very limited class of cases) (citing Sullivan v. Louisiana, 508 U.S. 275 (1993) (erroneous reasonabledoubt instruction to jury); Vasquez v. Hillery , 474 U.S. 254 (1986) (unlawful exclusion of grand jurors of defendant's race); Waller v. Georgia, 467 U.S. 39 (1984) (the right to a public trial); McKaskle v. Wiggins, 465 U.S. 168 (1984) (the right to self-representation at trial); Gideon v. Wainright, 372 U.S. 335 (1963) (a total deprivation of the right to counsel); Tumey v. Ohio, 273 U.S. 510 (1927) (lack of an impartial trial judge)); see also Neder v. United States , 527 U.S. 1, 8 (1999) (citing the same cases). Notably, neither Johnson nor Neder cited Stirone or listed constructive amendments as one of the narrow class of recognized structural errors. 35 in several of the fraud and False Claims Act counts for which he was convicted. As we explained above, we need not reach the question whether the evidence was sufficient to support the medical necessity theory on all of the counts in which it was alleged because each count contained an alternative theory of fraud that Syme does not challenge on this appeal. Therefore, under the rule from United States v. Griffin, 502 U.S. 46 (1991), we affirm the convictions, assuming that they rested on the factually supported ground. However, because we reverse count 25 and remand for a new trial thereon, we must consider Syme's challenge to the factual sufficiency of themedical necessity theory of fraud pleaded in that count. Citing Burks v. United States, 437 U.S. 1 (1978), Syme contends that if we find that there was not sufficient evidence presented at trial to support the medical necessity theory as it applies to count 25, we must exclude it from the new trial that we order on this count. Syme's trial counsel moved to dismiss the case for insufficient evidence at the close of the government's case, thus preserving the issue for appeal. We will review Syme's challenge to the sufficiency of the evidence to support the medical necessity theory of fraud in count 25 under the harmless error standard. See Fed R. Crim. P. 52(a). When the sufficiency of the evidence to support a jury's verdict is challenged, we must view the evidence in the light most favorable to the government and must sustain the jury's verdict if a reasonable jury believing the government's evidence could find beyond a reasonable doubt that the government proved all the elements of the offense. United States v. Pressler, 256 F.3d 144, 149 (3d Cir. 2001) (quoting United States v. Rosario, 118 F.3d 160, 163 (3d Cir. 1997)) (internal quotation marks and alterations omitted). In fact, only when the record contains no evidence, regardless of how it is weighted, from which the jury could find guilt beyond a reasonable doubt, may an appellate court overturn the verdict. United States v. Anderson, 108 F.3d 478, 481 (3d Cir. 1997) (quoting United States v. McNeill, 887 F.2d 448, 450 (3d Cir. 1989)) (internal quotation marks and alterations omitted). 36 Count 25 refers to an August 3, 1994 ambulance trip in which NCC transported 80-year-old patient Ruth Graham. Dr. Leaser, the government's expert medical witness, testified that, based on his review of Graham's medical files, it was his opinion that it was not necessary to transport Graham by ambulance. Leaser based his opinion that ambulance transport was not necessary for Graham largely on notes made by the medical personnel at the nursing home where Graham lived, which indicated that she was ambulatory and could sit up unassisted. He cited a record that stated that as of January 1994, Graham was able to ambulate without assistance. He also noted that Graham's records indicated that in late March 1994, she was able to sit up without assistance and participate in an occupational therapy session. But the government asked Leaser only if he had reviewed the medical records for Graham for [the] dates of service January 20th, 1994 and March 17th, 1994. Leaser did not mention consulting any medical evidence recorded after March 1994, and his testimony suggests that he did not review Graham's medical files for dates after March 1994. Leaser noted that, in addition to Graham's medical records near the January 20, 1994 and March 17, 1994 ambulance trips, he also looked at one other date . . . [on which] there was an ambulance transport . . . 2/16/94. (emphasis added). However, Graham's health could have deteriorated during the more than four months that passed between the date of the last medical record upon which Leaser relied and the August 3, 1994 ambulance trip in question. Therefore, although we view the evidence and the inferences logically deducible therefrom in the light most favorable to the government, McNeill, 887 F.2d at 450, we conclude that due to the government's failure to put forth any evidence more current than March 1994, no reasonable jury could find beyond a reasonable doubt that Graham's August 3, 1994 ambulance trip was not medically necessary. Because we conclude that the government presented insufficient evidence for a reasonable jury to have convicted Syme on count 25 based on the medical necessity theory in the first trial, we must address the question whether to 37 allow the government to retry that theory on remand, or to limit the remand exclusively to the treatment theory (which Syme does not challenge). Syme argues that Burks instructs this court not to allow the government to retry a theory on which the government presented insufficient evidence the first time around. In Burks, the Supreme Court considered whether the Double Jeopardy Clause of the U.S. Constitution bars an appellate court that reverses a conviction for insufficiency of the evidence presented at trial from remanding the count of conviction for a new trial. The court of appeals in Burks (1) found that at trial the Government had failed to come forward with sufficient proof of petitioner's capacity to be responsible for criminal acts, (2) held that the district court should have entered a judgment of acquittal in the first instance, and (3) remanded the case for a new trial. 437 U.S. at 10-11. The sole issue before the Supreme Court was whether it is proper for an appeals court to remand a case for a new trial after finding that the verdict was insufficiently supported by the evidence presented at trial. The Court found that it is not proper, holding that the Double Jeopardy Clause forbids a second trial for the purpose of affording the prosecution another opportunity to supply evidence which it failed to muster in the first proceeding. Id. at 11. The Court has stated that this principle, which prevents the State from honing its trial strategies and perfecting its evidence through successive attempts at conviction, lies at the core of the Clause's protections. Tibbs v. Florida, 457 U.S. 31, 41 (1982). While Burks held that it was improper to order retrial of a whole count that the evidence was insufficient to support, we see no reason why the Double Jeopardy Clause would not also bar retrial on an alternative theory of guilt that the evidence was insufficient to support in a single count of conviction. The government does not argue that this error was harmless. Therefore, we will restrict the scope of the new trial on count 25 to the treatment theory, excluding both the Pennsylvania rate theory (because it was not alleged in the indictment), and the medical necessity theory (because the government presented insufficient evidence to support it in the first trial). 38