Opinion ID: 2795466
Heading Depth: 2
Heading Rank: 1

Heading: Reasonable Medical Basis

Text: Staggs argues that the auditing cardiologist’s review of whether a diagnosis has a “reasonable medical basis” must defer to the claimant’s attesting physician. From this premise, he concludes that the attesting physician’s conclusion must be accepted if it is “not absurd, not ridiculous, not extreme, and not excessive.” Appellant Br. at 23. It is true that reasonable medical basis review commands a degree of deference: if an attesting physician declares a claimant qualifies for matrix benefits and an auditing 4 cardiologist or the District Court disagrees but nonetheless perceives a reasonable medical basis for the claim, the claim must be approved. But, even though those reviewing the diagnosis may only examine whether it has a reasonable medical basis and not impose their independent judgment of a claimant’s medical condition without regard to the attesting physician’s decision, it does not follow that the review is so deferential as to require approval of any claim unless it is patently absurd. Rather than the standard Staggs urges, we adhere to the definition in our precedent and the Audit Training Module: a “reasonable medical basis” is a foundation for a diagnosis by an unbiased physician using “normal clinical judgment and accepted medical standards.” J.A. 1489–90. A reasonable medical basis also exists when a diagnosis results from faithful application of the District Court’s orders on “the requirements for reading an echocardiogram, see PTO 2640” and “the Auditing Cardiologist Training Course, see PTO 2825.” In re Diet Drugs (Phentermine/ Fenfluramine/Dexfenfluramine) Prods. Liab. Litig., 543 F.3d 179, 189 n.16 (3d Cir. 2008).