Opinion ID: 1310279
Heading Depth: 1
Heading Rank: 3

Heading: Sufficiency of the evidence to convict Martinez of health care fraud resulting in death

Text: 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, 99 S.Ct. 2781. 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 Fed.Appx. 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. 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). i. John Lancaster 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 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 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 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 the circumstances and, therefore, not an independent intervening cause breaking the chain of proximate causation). ii. Blair Knight 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 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.
Related to the issue of causation, Martinez contends that the district court erred in admitting testimony from Dr. Parran, an addiction specialist who teaches at Case Western Reserve School of Medicine. Dr. Parran testified that the drugs prescribed by Dr. Martinez caused the deaths of Lancaster and Knight. Martinez objected to Dr. Parran's testimony at trial, but the district court overruled the objection. On appeal, Martinez argues that the court impermissibly allowed Dr. Parran to speculate as to the causes of Lancaster's and Knight's deaths. We review the district court's ruling admitting or excluding expert testimony under an abuse-of-discretion standard. Kumho Tire Co. v. Carmichael, 526 U.S. 137, 142, 119 S.Ct. 1167, 143 L.Ed.2d 238 (1999). Rule 702 of the Federal Rules of Evidence provides: If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the form of an opinion or otherwise, if (1) the testimony is based upon sufficient facts or data, (2) the testimony is the product of reliable principles and methods, and (3) the witness has applied the principles and methods reliably to the facts of the case. Under Rule 702, the district court must examine the expert witness's testimony for reliability and relevance. Our review of the district court's admission of expert testimony must focus, of course, [] solely on principles and methodology, not on the conclusions that they generate, Daubert v. Merrell Dow Pharms., Inc., 509 U.S. 579, 595, 113 S.Ct. 2786, 125 L.Ed.2d 469 (1993), and we must confirm that the factual underpinnings of the expert's opinions were sound, Greenwell v. Boatwright, 184 F.3d 492, 498 (6th Cir.1999). However, [v]igorous cross-examination, presentation of contrary evidence, and careful instruction on the burden of proof are the traditional and appropriate means of attacking shaky but admissible evidence. Daubert, 509 U.S. at 596, 113 S.Ct. 2786. At trial, Dr. Parran testified that Lancaster's overdose resulted from medication prescribed by Martinez, but on cross-examination he testified that he could not say beyond a reasonable doubt that the medicine prescribed caused Lancaster's death. (JA 2231.) With respect to Knight's death, Dr. Parran testified that the prescription from Martinez directly and causally contributed, such that if it [had not] been for that prescription, Knight would not have overdosed. (JA 2219.) First, we observe that this testimony was not admitted in error because it is more than the sort of unsupported speculation that is prohibited, as it was based on Parran's examination of the toxicology reports and the patients' files. See McLean v. 988011 Ontario, Ltd., 224 F.3d 797, 801 (6th Cir. 2000) (noting that an expert's conclusions regarding causation must have a basis in established fact and cannot be premised on mere suppositions, and if based on assumed facts, must find some support for those assumptions in the record). Thus, we conclude that Dr. Parran's testimony was not admitted in error. Further, the jury was instructed to consider whether the course of treatment proximately caused the deaths of Lancaster and Knightnot simply whether the oral prescriptions themselves resulted in their deaths. Given the evidence from which a rational jury could find that Martinez's course of treatment proximately caused the deaths of Lancaster and Knight, we also conclude that any error in admitting Parran's testimony was harmless. Baker, 458 F.3d at 520.

Martinez argues that his sentence was both procedurally and substantively unreasonable and that the district court's loss calculation used to set the appropriate amount of restitution was not supported by the evidence. We review challenges to the district court's sentencing determinations for reasonableness under an abuse-of-discretion standard. Gall v. United States, 552 U.S. 38, 56, 128 S.Ct. 586, 169 L.Ed.2d 445 (2007); Rita v. United States, 551 U.S. 338, 361, 127 S.Ct. 2456, 168 L.Ed.2d 203 (2007); United States v. Booker, 543 U.S. 220, 261, 125 S.Ct. 738, 160 L.Ed.2d 621 (2005). The reasonableness inquiry has both procedural and substantive components. United States v. Caver, 470 F.3d 220, 248 (6th Cir.2007). Accordingly, we must `consider not only the length of the sentence but also the factors evaluated and the procedures employed by the district court in reaching its sentencing determination.' United States v. Moon, 513 F.3d 527, 539 (6th Cir.2008) (quoting United States v. Webb, 403 F.3d 373, 383 (6th Cir.2005)).
Martinez contends his sentence is procedurally unreasonable because the district court failed to: (1) explain the calculation of the United States Sentencing Guidelines (U.S.S.G. or Guidelines) range, (2) address Martinez's objections to the Guidelines range as calculated in the Presentence Investigation Report (PSR), (3) consider the 18 U.S.C. § 3553(a) factors, and (4) explain the sentence imposed. Martinez also argues that the district court improperly relied on the jury's implied findings not contained in the verdict. In our review of a sentence for procedural reasonableness, we must ensure that the district court committed no significant procedural error, such as failing to calculate (or improperly calculating) the Guidelines range, treating the Guidelines as mandatory, failing to consider the § 3553(a) factors, selecting a sentence based on clearly erroneous facts, or failing to adequately explain the chosen sentence. Gall, 552 U.S. at 51, 128 S.Ct. 586. Our `reasonableness review focuses on the factors listed in § 3553(a), one of which is the Sentencing Guidelines themselves.' Moon, 513 F.3d at 539 (quoting United States v. Duckro, 466 F.3d 438, 442 (6th Cir.2006)). We may conclude that a sentence is unreasonable when the district court fails to `consider' the applicable Guidelines range or neglects to `consider' the other factors listed in 18 U.S.C. § 3553(a), and instead simply selects what the judge deems an appropriate sentence without such required consideration. Moon, 513 F.3d at 539 (citing United States v. Jones, 489 F.3d 243, 250-51 (6th Cir.2007)). The § 3553(a) factors are: (1) the nature and circumstances of the offense and the history and characteristics of the defendant; (2) the need for the sentence to reflect the seriousness of the offense, to promote respect for the law, and to provide just punishment for the offense; to protect the public from further crimes of the defendant; and to provide the defendant with needed educational or vocational training, medical care, or other correctional treatment in the most effective manner; (3) the kinds of sentences available; (4) the appropriate advisory guideline range; (5) any other pertinent policy statement issued by the Sentencing Commission; (6) the need to avoid unwarranted sentence disparities among defendants with similar records who have been found guilty of similar conduct; and (7) the need to provide restitution to any victims of the offense. Caver, 470 F.3d at 248 (quoting 18 U.S.C. § 3553(a)). [T]he district court need not `engage in a ritualistic incantation' of the § 3553(a) factors, but its decision should be sufficiently detailed to reflect the considerations listed in § 3553(a) to permit meaningful appellate review. Moon, 513 F.3d at 539 (quoting United States v. McBride, 434 F.3d 470, 474 (6th Cir.2006)). The district court's [decision] must also provide some indication that the court considered the defendant's arguments in favor of a lower sentence and the basis for rejecting such arguments. Id. (citing Jones, 489 F.3d at 250-51). At the sentencing hearing, the district court made an initial finding that there is a total offense level of 43 with a Criminal History Category I, and then explained the sentences that this calculation initially allowed for under each of the counts. (JA 870.) This calculation was the same as that reached in the PSR, a range to which Martinez objected both in writing and at his sentencing hearing. According to the PSR, this calculation was reached in the following manner: The base level offense was 7, 24 additional levels were added for a loss of more than $50 million, 2 additional levels were added because the offense involved conscious or reckless risk of death, 2 additional levels were added because the offense involved sophisticated means, 6 additional levels were added because the offense involved 250 or more victims, 2 additional levels were added because the victims were vulnerable, 4 additional levels were added because Martinez was the organizer and leader of extensive criminal activity, and 2 additional levels were added because Martinez was in a position of trust. This resulted in an offense level of 49, which was adjusted downward to the maximum offense level of 43, resulting in an advisory Guidelines sentence of life imprisonment. In his objections to the PSR, Martinez objected to this calculation for a variety of reasons. However, at sentencing, his objection focused on the district court's method-of-loss calculation and the enhancement for vulnerable victims. Martinez's brief addresses only the district court's calculation of loss. Therefore, Martinez has forfeited any other challenge to the Guidelines calculation. Crozier, 259 F.3d at 517.
Martinez argues that the court calculated the loss caused by his crimes incorrectly. We disagree. As an initial matter, we note that the district court explained the method used to calculate the loss caused by Martinez's crimes, and we review a district court's calculation of the amount of loss for clear error. United States v. Blackwell, 459 F.3d 739, 772 (6th Cir.2006). In order to challenge this calculation, Martinez must carry the burden of demonstrating `that the court's evaluation of the loss was not only inexact but outside the universe of acceptable computations.' United States v. Raithatha, 385 F.3d 1013, 1024 (6th Cir.2004), vacated and remanded on other grounds, 543 U.S. 1136, 125 S.Ct. 1348, 161 L.Ed.2d 94 (2005) (quoting United States v. Tardiff, 969 F.2d 1283, 1288 (1st Cir.1992)). When determining the amount of loss for sentencing purposes, a defendant will be held accountable for the actual or intended loss to a victim, whichever is greater, or a combination thereof. Id. (citing United States v. Wade, 266 F.3d 574, 586 (6th Cir.2001)); see also U.S.S.G. § 2B1.1, cmt. n. 3(A)(ii). Moreover, [s]o long as the intended loss is supported by a preponderance of the evidence, the district court may use it in reaching the appropriate offense level. Raithatha, 385 F.3d at 1024 (quoting United States v. Logan, 250 F.3d 350, 371 (6th Cir.2001)). Following a verdict, restitution is properly ordered in the full amount of each victim's loss. See 18 U.S.C. § 3664(f)(1)(A). The term `victim' is defined as `a person directly and proximately harmed by a defendant's offense.' Hunt, 521 F.3d at 648 (quoting 18 U.S.C. § 3663A(a)(2)). During the sentencing hearing, the court questioned the parties regarding loss calculation. Martinez argued that the amount would properly be calculated at approximately $45,000 because that was the loss corresponding to the exact charges on the indictment. The court, in turn, articulated the Government's position and said that the treatment that was given and the bills that were either submitted or intended to be submitted by Martinez were not for medical treatment, and therefore all the bills that Martinez submitted were properly covered in the calculation of intended loss. (JA 888.) The Government supplemented this explanation, noting that all of the fraud counts included an allegation that Martinez devise[d] a scheme to defraud, and that the Government presented proof that the scheme ran from January 1998 until September 2004. (JA 893-894.) Because the charges referred not only to the specific charges in the indictment, but also to the entire scheme underlying the fraud, the total intended loss connected to the wire and mail fraud was properly included, resulting in an actual loss of more than $12,337,230 for payments actually made to Martinez and an intended loss of $60,799,000 for bills submitted by Martinez. These calculations were supported by the testimony of representatives from BWC, Medicare, and Medicaid concerning the amounts Martinez billed them and the payments Martinez received; by the expert testimony of statistician Dr. Michael Nowak, who presented these calculations during trial; and by the testimony of Dr. Kennedy, who examined the patient files and bills submitted by Martinez. Because [the health care benefit programs] would not have paid for [the procedures] but for the presence of [Martinez's] signature on the orders, [Martinez] was the direct and proximate cause of the harm suffered by those entities. Hunt, 521 F.3d at 648. Thus, the district court did not commit error when it accepted the reimbursement amounts over the years which Martinez was committing the fraud when it ordered restitution. Further, it is appropriate for the court to consider the nature of the fraud in determining whether the loss amount should be limited to the specific losses testified to or to an amount derived from the nature of the fraud. Id. (rejecting defendant's argument that only the specific amounts proven could be included in the loss calculation, and accepting estimates for loss based on the Government's sample and average figures provided by the insurance companies). Because the district court did not err in including the total amount of intended loss in its calculation, Martinez cannot show that the calculation of loss was incorrect.
The court also recognized that the Guidelines are advisory and noted that it had reviewed all of Martinez's objections to the PSR. Here, the district court gave both parties an opportunity to argue for what they deemed an appropriate sentenceMartinez argued for a sentence of time served, and the Government argued for a sentence within the Guidelines. Following a lengthy presentation by the Government of documents in support of a Guidelines sentence in this case, the district court gave Martinez an opportunity to argue for a downward variance. Martinez asked the court not to impose a draconian penalty and professed his innocence, arguing that his actions were merely an attempt to relieve his patients' pain. Martinez also disclaimed responsibility for the deaths of Lancaster and Knight, contending that he was not responsible for their drug overdoses. He further requested leniency, arguing that a lower sentence was warranted based on his years of service to his patients and his status as a non-citizen. The record reflects that the district court considered and rejected Martinez's arguments. The court's reasoning in doing so was sufficiently detailed to reflect the considerations listed in § 3553(a) and to allow for meaningful appellate review. United States v. Mayberry, 540 F.3d 506, 518 (6th Cir.2008) (internal quotation marks omitted). Although the court acknowledged that some patients were satisfied with the care provided by Martinez, it found that he had hurt many more. In response to Martinez's argument that the Guidelines sentence was draconian, the court explained: [P]eople who were helpless came to [Martinez] as their last hope, and [he] didn't treat them according to medical standards; [he] ... continued their addiction to narcotic drugs, and [he] didn't get them better; they only got worse. And during this course of treatment, at least two people died as a result of the fraud and distribution of drugs. That being the case, the sentences don't seem to be draconian. (JA 932.) The court also remarked, the point is, [Lancaster and Knight] came, sought treatment, and they were in desperation, and [] you continued to prescribe drugs that would continue [their] downward spiral, that resulted in [their overdoses], and that's why you are responsible [for their deaths]. (JA 933-34.) Before announcing Martinez's life sentence, the court stated that it was relying on the findings that it had made under 18 U.S.C. § 3553(a). Although the district court did not address Martinez's pleas for a lower sentence based on his years of service to his patients and his status as a non-citizen, its failure to do so is not procedurally unreasonable. See United States v. Liou, 491 F.3d 334, 339 n. 4 (6th Cir.2007) (noting that a district court's failure to address each argument [of the defendant] head-on will not lead to automatic vacatur (citing Rita v. United States, 551 U.S. 338, 358, 127 S.Ct. 2456, 168 L.Ed.2d 203 (2007))).
In addition to procedural reasonableness, we must determine whether Martinez's sentence is substantively reasonable. United States v. Webb, 403 F.3d 373, 383 (6th Cir.2005). A sentence may be substantively unreasonable where the district court `select[s] the sentence arbitrarily, bas[es] the sentence on impermissible factors, fail[s] to consider pertinent § 3553(a) factors or giv[es] an unreasonable amount of weight to any pertinent factor.' United States v. Collington, 461 F.3d 805, 808 (6th Cir.2006) (quoting Webb, 403 F.3d at 383). We have held that sentences within a properly calculated Guidelines range are afforded a rebuttable presumption of reasonableness, and the defendant bears the burden of rebutting this presumption. Caver, 470 F.3d at 247 (citing United States v. Williams, 436 F.3d 706, 708 (6th Cir.2006)). Martinez has failed to rebut that presumption, and we conclude that his sentence is substantively reasonable.
Martinez raises a number of additional pro se claims, but we decline to address them because he is represented by counsel. United States v. Howton, 260 Fed. Appx. 813, 819 (6th Cir.2008) (We decline to address [the defendant's pro se] arguments because [the defendant] was represented by counsel in this matter.). Even if we did address such claims, they are without merit.
For the foregoing reasons, we AFFIRM Martinez's conviction and sentence.