Court Opinion

ID: 2645134
Source: CourtListenerOpinion
Date Created: 2013-12-06 20:30:49.188173+00
Date Added: 2024-06-11T09:04:02.844991
License: Public Domain

United States Court of Appeals
                        For the First Circuit

No. 13-1088

                UNITED STATES ex rel. HELEN GE, M.D.,

                         Relator, Appellant,

      STATE OF CALIFORNIA; STATE OF DELAWARE; STATE OF FLORIDA;
   STATE OF GEORGIA; STATE OF HAWAII; STATE OF ILLINOIS; STATE OF
       LOUISIANA; STATE OF INDIANA; STATE OF MICHIGAN; STATE OF
     MINNESOTA; STATE OF MONTANA; STATE OF NEVADA; STATE OF NEW
HAMPSHIRE; STATE OF NEW JERSEY; STATE OF NEW MEXICO; STATE OF NEW
 YORK; STATE OF NORTH CAROLINA; STATE OF OKLAHOMA; STATE OF RHODE
  ISLAND; STATE OF TENNESSEE; STATE OF TEXAS; STATE OF WISCONSIN;
      COMMONWEALTH OF MASSACHUSETTS; COMMONWEALTH OF VIRGINIA;
                         DISTRICT OF COLUMBIA,

                             Plaintiffs,

                                  v.

                TAKEDA PHARMACEUTICAL COMPANY LIMITED;
              TAKEDA PHARMACEUTICAL NORTH AMERICA, INC.,

                        Defendants, Appellees.

No. 13-1089

                UNITED STATES ex rel. HELEN GE, M.D.,

                         Relator, Appellant,

 STATE OF CALIFORNIA; STATE OF DELAWARE; STATE OF FLORIDA; STATE
      OF GEORGIA; STATE OF HAWAII; STATE OF ILLINOIS; STATE OF
     LOUISIANA; STATE OF INDIANA; STATE OF MINNESOTA; STATE OF
  MONTANA; STATE OF NEVADA; STATE OF NEW HAMPSHIRE; STATE OF NEW
  JERSEY; STATE OF NEW MEXICO; STATE OF NEW YORK; STATE OF NORTH
   CAROLINA; STATE OF OKLAHOMA; STATE OF RHODE ISLAND; STATE OF
  TENNESSEE; STATE OF TEXAS; STATE OF WISCONSIN; COMMONWEALTH OF
  MASSACHUSETTS; COMMONWEALTH OF VIRGINIA; DISTRICT OF COLUMBIA,

                             Plaintiffs,

                                  v.
             TAKEDA PHARMACEUTICAL COMPANY LIMITED;
           TAKEDA PHARMACEUTICAL NORTH AMERICA, INC.,

                      Defendants, Appellees.

          APPEALS FROM THE UNITED STATES DISTRICT COURT
                FOR THE DISTRICT OF MASSACHUSETTS

         [Hon. F. Dennis Saylor IV, U.S. District Judge]

                              Before

                       Lynch, Chief Judge,
                Stahl and Howard, Circuit Judges.

     Michael Sullivan, with whom The Ashcroft Group, Michael L.
Baum, Bijan Esfandiari, R. Brent Wisner, and Baum, Hedlund, Aristei
& Goldman, P.C. were on brief, for appellant.
     Brian J. Murray, with whom Morgan R. Hirst, Marron A. Mahoney,
Christopher M. Morrison, Joseph B. Sconyers, and Jones Day were on
brief, for appellees.
     Melissa N. Patterson, Attorney, Appellate Staff, Civil
Division, with whom Stuart F. Delery, Acting Assistant Attorney
General, Carmen M. Ortiz, United States Attorney, and Michael S.
Rabb, Attorney, Appellate Staff, Civil Division, were on brief, for
the United States of America as Amicus Curiae.

                         December 6, 2013
           LYNCH, Chief Judge. In June 2010 Dr. Helen Ge originally

filed these two qui tam actions against her former employer, Takeda

Pharmaceutical     Company    Ltd.     and     its     subsidiary        Takeda

Pharmaceutical North America, Inc. (collectively, "Takeda"), under

the federal False Claims Act ("FCA"), 31 U.S.C. § 3729 et seq., and

various   analogous   state   statutes.       The     two    actions   concern

different drugs.      She has since amended each of her complaints

twice.    The United States has declined to enter the case as a

party.    In a successful qui tam action, the relator collects a

portion of the award to the government regardless of whether the

government intervenes.     See United States ex rel. Duxbury v. Ortho

Biotech Prods., L.P. ("Duxbury I"), 579 F.3d 13, 16 (1st Cir.

2009).

           Dr. Ge has alleged in her second amended complaints that

Takeda had failed to disclose adequately the risks associated with

four of its drugs and generally that this failure resulted in the

submission of false claims by various third-party patients and

physicians for government payment through, for example, Medicare or

Medicaid reimbursement.

           On   Takeda's   motions    to   dismiss,    the    district    court

dismissed both of Dr. Ge's actions under Federal Rule of Civil

Procedure 9(b) for failure to plead fraud with particularity and,

in addition, under Federal Rule of Civil Procedure 12(b)(6) for

failure to state a claim.       United States ex rel. Ge v. Takeda

                                     -3-
Pharm. Co. Ltd., Nos. 10-11043-FDS, 11-10343-FDS, 2012 WL 5398564

(D. Mass. Nov. 1, 2012).            Dr. Ge proposed to amend the second

amended complaint yet again, asserting still more theories of FCA

liability. The district court declined to allow further amendment.

             Dr. Ge now appeals, making three levels of arguments:

(1) as to the Rule 9(b) dismissal, that her complaints contain

sufficient allegations concerning "the who, what, where, and when"

of   Takeda's   misconduct     to    satisfy     Rule   9(b)'s   particularity

requirement, see Duxbury I, 579 F.3d at 30 (quoting Rodi v. S. New

Eng. Sch. of Law, 389 F.3d 5, 15 (1st Cir. 2004)) (internal

quotation    mark    omitted),      (2)    the   district   court   abused    its

discretion in rejecting without opinion two requests, one pre-

judgment and one post-judgment, by Dr. Ge to amend her complaints

again, and (3) as to Rule 12(b)(6), that the district court's

analysis    relies   on   an   overly       restrictive     conception   of   FCA

liability.

             This opinion concerns the first two arguments. We affirm

the district court on its Rule 9(b) and denial of amendment

rulings, and do not reach the 12(b)(6) issue.

                                          I.

             In September 2008, Dr. Ge took a position with Takeda as

a contract physician, contracting to perform medical reviews of

adverse event reports.         Dr. Ge was responsible for reports of

adverse events, including those concerning four specific drugs for

                                          -4-
specific         diseases:      Actos   (type      2     diabetes),   Uloric    (gout),

Kapidex/Dexilant (gastroesophageal reflux disease), and Prevacid

(same).          Takeda sells all four drugs and each required Food and

Drug Administration ("FDA") approval for these uses.                           Dr. Ge's

tasks included ascertaining the seriousness of a reported event,

determining whether the associated drug was causally responsible

for that event, and determining whether that event constituted a

"safety signal," that is whether the reported event signaled the

need for additional safety warnings.                      Dr. Ge worked for Takeda

until January 2010.             She asserts that when she complained about

improper         reporting      at   Takeda,       her    contract    was    summarily

terminated.

                 On June 18, 2010, Dr. Ge filed an FCA complaint under

seal against Takeda pertaining to Actos.                     United States ex rel.

Helen Ge v. Takeda Pharmaceutical Co., et al, 10-11043-FDS.                           On

March       1,    2011,   Dr.   Ge   filed    a    second    complaint      under   seal

pertaining to Uloric, Kapidex/Dexilant, and Prevacid.                            United

States ex rel. Helen Ge v. Takeda Pharmaceutical Co., et al,

11-10343-FDS. In Dr. Ge's complaints, she alleged on behalf of the

United States1 that three FCA sections were violated: (a) 31 U.S.C.

        1
         Dr. Ge's complaints also brought claims on behalf of
California, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana,
Louisiana, Massachusetts, Michigan, Minnesota, Montana, Nevada, New
Hampshire, New Jersey, New Mexico, New York, North Carolina,
Oklahoma, Rhode Island, Tennessee, Texas, Virginia, Wisconsin, and
the District of Columbia, alleging violations by Takeda of similar
state statutes. Michigan is only a party to the Actos appeal.

                                             -5-
§   3729(a)(1)(A),     which     imposes    liability     on   any   person      who

"knowingly      presents,   or   causes     to   be   presented,     a   false   or

fraudulent claim for payment or approval," (b) § 3729(a)(1)(B),

which imposes liability on any person who "knowingly makes, uses,

or causes to be made or used, a false record or statement material

to a false or fraudulent claim," and (c) § 3729(a)(1)(C), which

imposes liability on any person who conspires to commit a violation

of, among other things, § 3729(a)(1)(A) or § 3729(a)(1)(B).

            In late 2011 and early 2012, Dr. Ge filed amended

complaints in both cases while both complaints were still under

seal.     Between late March and early April 2012, Dr. Ge filed a

second    set   of   amended     complaints      after   the   complaints     were

unsealed. Dr. Ge's second amended complaints are the ones directly

at issue on appeal.

            Dr. Ge alleged Takeda had failed to report promptly and

accurately to the FDA a number of post-approval adverse events

associated with the four subject drugs. The FDA is responsible for

the approval of drugs for commercial marketing.                  See 21 U.S.C.

§ 355.      The FDA is authorized after approval to continue to

evaluate the safety and effectiveness of the drug and, where

appropriate, to withdraw approval or require a change in labeling.

See id. § 355(k). FDA regulations require prompt, accurate reports

of adverse drug events by drug manufacturers. 21 C.F.R. §§ 314.80,

314.81.    The receipt of an adverse report does not in and of itself

                                      -6-
show a causal relationship between a drug and the illness mentioned

in a report.   N.J. Carpenters Pension & Annuity Funds v. Biogen

Idec, Inc., 537 F.3d 35, 53 (1st Cir. 2008).

           It is undisputed that Takeda did submit adverse event

reports and there is no specific allegation that any of the events

which are the subject of the complaint were not eventually reported

in some form to the FDA.   As to the drug Actos, Dr. Ge alleged that

she was asked by Takeda to misreport adverse events including

incidences of heart failure, renal failure, pancreatic cancer, and,

most notably, bladder cancer.     Dr. Ge alleged that she complied

with those directions on certain occasions after having made known

her   objections.   In   addition,   Dr.   Ge   alleged   that   she   had

discovered systematic under-reporting by Takeda of the incidence of

bladder cancer in adverse event reports.

           The FDA did receive information on bladder cancer risk

because in June 2011, the FDA issued an official warning "that use

of the diabetes medication Actos (pioglitazone) for more than one

year may be associated with an increased risk of bladder cancer."

FDA Drug Safety Communication: Update to ongoing safety review of

Actos (pioglitazone) and increased risk of bladder cancer (June 15,

2011), http://www.fda.gov/Drugs/DrugSafety/ucm259150.htm. The FDA

also mandated a label change.        FDA Drug Safety Communication:

Updated drug labels for pioglitazone-containing medicines (Aug. 4,

2011), http://www.fda.gov/drugs/drugsafety/ucm266555.htm.         But it

                                 -7-
also issued a supplemental approval of Actos after knowing of the

bladder cancer risk. Dr. Ge alleges that after the labeling change

the sales of Actos plummeted.

               As to the drugs Uloric, Kapidex/Dexilant, and Prevacid,

Dr. Ge alleged that Takeda pressured her to falsify her medical

conclusions, asking her to classify events as "non-serious" or to

change her causality assessment to "unrelated" so as to avoid

"reporting within 15 days" as required by FDA regulation.                     See 21

C.F.R.     §   314.80(c)(1)(i)      (requiring         report   of   "serious     and

unexpected" adverse event within 15 days).                 Specifically, Dr. Ge

alleged that she was directed to alter her analysis of reported

adverse events involving the interactions between the three drugs

and other medications likely to be taken by senior citizens.                      Dr.

Ge   did   not      clearly   allege     that    she    complied     with   Takeda's

directions.         Dr. Ge did allege, however, that on various occasions

Takeda officials altered her assessments directly.

               As    to   Uloric,   at    some    point    Takeda     submitted     a

Supplemental New Drug Application to update the Adverse Reactions

section of the Uloric label.             The FDA approved this supplemental

application on January 28, 2011.2

      2
        At times Dr. Ge's complaint appears to be directed against
the FDA for its failure to require greater warnings on labels, such
as for Prevacid.

                                         -8-
           As to all four drugs Dr. Ge asserts that Takeda should

have reported adverse events earlier, and that Takeda consistently

took actions to resist label changes through under-reporting.

           On May 11, 2012, Takeda filed its motion to dismiss. Dr.

Ge filed a memorandum in opposition on July 17, 2012.      At the end

of her memorandum but not as a separate motion, Dr. Ge requested

leave to amend her complaints a third time, if the court was

inclined to dismiss, and supported it with a declaration from one

of her attorneys that included an attachment providing the total

expenditures by the federal government for Actos.       On August 27,

2012, Takeda filed a motion to strike that declaration.

           On November 1, 2012, the district court dismissed in a

written order Dr. Ge's claims under Rule 9(b), reasoning that

"although relator has alleged facts that would demonstrate a

'fraud-on-the-FDA' with respect to intentional under-reporting of

adverse events, she has failed to allege the specific details of

any claims that were allegedly rendered 'false' as a result."

Takeda, 2012 WL 5398564, at *4.     The district court noted that Dr.

Ge had attempted to cure this defect by referring to her attorney's

declaration, which attached the total aggregate expenditure data by

the government for Actos.    Id.   The district court held, however,

that even assuming it was permissible for the court to consider the

Actos data, such aggregate expenditure data did not satisfy Rule

9(b)'s   particularity   requirement.     Id.    The   district   court

                                   -9-
contrasted Dr. Ge's pleadings with the pleadings of the relator in

Duxbury I, which identified eight specific medical providers who

allegedly    submitted    false    claims,     the   rough   time    periods,

locations, and amounts of the claims, and the specific government

programs to which the claims were made.          Takeda, 2012 WL 5398564,

at *4 (citing Duxbury I, 579 F.3d at 29-30).

            From   the   absence   of   such     specifics   in     Dr.    Ge's

complaints, the district court inferred that Dr. Ge meant to assert

that all claims for the subject drugs during the relevant time

period were rendered false by Takeda's alleged misconduct.                Id. at

*5.   The district court held that Dr. Ge had not provided the

specific factual allegations necessary to support the inference

that the FDA would have withdrawn approval from all four drugs

immediately upon receiving the withheld information. Id.; see also

21 C.F.R. §§ 314.80(j), 314.81(d) ("If an applicant fails to

establish and maintain records and make reports required under this

section, FDA may withdraw approval of the application and, thus,

prohibit continued marketing of the drug product that is the

subject of the application.") (emphasis added). The district court

went beyond that to point out that even were it to accept the

unsubstantiated premise that drugs would have been taken off the

market, there were still no allegations about how the fraudulent

reporting would render false those claims which were filed before

the adverse events occurred.

                                    -10-
            In the same November 1, 2012 order, the district court

also dismissed Dr. Ge's claims under Rule 12(b)(6) for failure to

state a claim, holding that Dr. Ge had not adequately established

that compliance with adverse-event reporting requirements was a

"material precondition" to the payment of the claims at issue.

Takeda, 2012 WL 5398564, at *6; see also United States ex rel.

Hutcheson v. Blackstone Med., Inc., 647 F.3d 377, 392 (1st Cir.

2011) (holding that FCA liability exists where claims submitted

"misrepresented compliance with a precondition of payment so as to

be false or fraudulent" and where "those misrepresentations were

material").     The district court observed that it is within the

FDA's    discretion   to   respond    to     violations   of   adverse-event

reporting requirements in a number of ways, only the harshest of

which is the withdrawal of drug approval. Takeda, 2012 WL 5398564,

at *6.     The district court noted in addition that the FDA's

enforcement procedures provide the opportunity for citizens to

petition the FDA to bring action against specific violators.               Id.

(citing 21 C.F.R. § 10.30). The district court reasoned that "[i]t

is through that mechanism, rather than an FCA lawsuit, that relator

should   have   brought    the   reporting    issues    illuminated   in   the

complaints to the attention of the FDA."          Id.

            Finally, the district court dismissed in that same order

Dr. Ge's various state-law claims both because they failed to state

a claim under state law and because they failed to plead with

                                     -11-
specificity the details of any claims for payment made to any of

the states.   Id.   The district court did not address Dr. Ge's

request for leave to amend. Judgment was entered for defendants on

November 1, 2012.

           On November 29, 2012, Dr. Ge filed a formal motion for

reconsideration pursuant to Rule 59(e) along with a motion for

leave to amend her complaint.   Dr. Ge's motions were supported by

(a) an economic model constructed by a pharmaceutical economics

professor from the School of Pharmacy at the University of Southern

California purporting to show the amount of claims for Actos that

would not have been submitted for government payment but for

Takeda's alleged misconduct, and (b) the declarations of eight

individuals attesting that an individual patient would not have

submitted his or her claim if Takeda had promptly and accurately

disclosed the link between Actos and bladder cancer.   On December

18, 2012, the district court denied Dr. Ge's motions without

opinion.   On January 14, 2013, Dr. Ge filed a timely notice of

appeal.3

     3
       Appearing as amicus curiae in support of neither party, the
United States makes a limited argument that the district court
erred in its Rule 12(b)(6) analysis to the extent that it reasoned
(1) the availability of alternative administrative remedies
precludes FCA liability, and (2) the failure to comply with FDA
post-approval reporting requirements is per se immaterial to the
Government's decision whether to reimburse a claim and hence could
under no circumstances serve as a basis for FCA liability.
According to the United States, failure to comply with FDA post-
approval reporting requirements could serve as a basis for FCA
liability only in "rare circumstances." It was objecting only to

                                -12-
                                 II.

            We review de novo the district court's dismissal order

for failure to comply with Rule 9(b).    United States ex rel. Gagne

v. City of Worcester, 565 F.3d 40, 45 (1st Cir. 2009).       Rule 9(b)

provides:    "In alleging fraud or mistake, a party must state with

particularity the circumstances constituting fraud or mistake."

Fed. R. Civ. P. 9(b).

            The district court correctly cited the relevant pleading

requirements:       Relators   are   required   to   set   forth   with

particularity the "'who, what, when, where, and how' of the alleged

fraud."     United States ex. rel Walsh v. Eastman Kodak Co., 98 F.

Supp. 2d 141, 147 (D. Mass. 2000) (quoting United States ex rel.

Thompson v. Columbia/HCA Healthcare Corp., 125 F.3d 899, 903 (5th

Cir. 1997)); see also Arruda v. Sears, Roebuck & Co., 310 F.3d 13,

18-19 (1st Cir. 2002).

            As we noted a few months ago in United States ex rel.

Duxbury v. Orthobiotech Products, L.P. ("Duxbury II"), 719 F.3d 31,

33 (1st Cir. 2013):

            "Although [the FCA's] financial incentive
            encourages would-be relators to expose fraud,"
            United States ex rel. Poteet v. Bahler Med.,
            Inc., 619 F.3d 104, 107 (1st Cir. 2010), it
            also attracts "'parasitic' relators who bring

a per se approach.    The United States takes no position as to
whether Dr. Ge's complaints contain sufficient allegations to state
a claim for purposes of Rule 12(b)(6). Nor does the United States
take a position as to whether Dr. Ge's pleadings satisfy the
particularity requirement of Rule 9(b).

                                 -13-
           FCA damages claims based on information within
           the public domain or that the relator did not
           otherwise discover," United States ex rel.
           Rost v. Pfizer, Inc., 507 F.3d 720, 727 (1st
           Cir. 2007).

For those reasons, there are a number of limitations on qui tam

actions, including the particularity requirements of Rule 9(b).

           As we explained in United States ex rel. Karvelas v.

Melrose-Wakefield Hospital, 360 F.3d 220 (1st Cir. 2004):

           [A] relator must provide details that identify
           particular false claims for payment that were
           submitted to the government. In a case such
           as this, details concerning the dates of the
           claims, the content of the forms or bills
           submitted, their identification numbers, the
           amount of money charged to the government, the
           particular goods or services for which the
           government   was   billed,   the   individuals
           involved in the billing, and the length of
           time between the alleged fraudulent practices
           and the submission of claims based on those
           practices are the types of information that
           may help a relator to state his or her claims
           with particularity.     These details do not
           constitute    a    checklist   of    mandatory
           requirements that must be satisfied by each
           allegation included in a complaint. However,
           . . . we believe that "some of this
           information for at least some of the claims
           must be pleaded in order to satisfy Rule
           9(b)."

Id. at 232-33 (quoting United States ex rel. Clausen v. Lab. Corp.

of Am., 290 F.3d 1301, 1312 n.21 (11th Cir. 2002)).           Karvelas also

rejects the notion that the Rule 9(b) pleading standard is relaxed

for FCA claims.    See id. at 228-31.

           In a qui tam action in which the defendant is alleged to

have   induced    third   parties   to     file   false   claims   with   the

                                    -14-
government, a relator can satisfy this requirement by "providing

'factual or statistical evidence to strengthen the inference of

fraud beyond possibility' without necessarily providing details as

to each false claim."      Duxbury I, 579 F.3d at 29 (quoting Rost, 507
F.3d at 733).

             Because FCA liability attaches only to false claims,

Karvelas, 360 F.3d at 225, merely alleging facts related to a

defendant's alleged misconduct is not enough, Rost, 507 F.3d at

732-33.      Rather,   a   complaint      based      on    §    3729(a)(1)(A)     must

"sufficiently    establish      that    false    claims        were   submitted   for

government    payment"     as   a   result      of   the       defendant's   alleged

misconduct.     Rost, 507 F.3d at 733.

             We will assume that the district court was correct that,

as to the allegations of fraud on the FDA, the alleged misconduct

suffices. Dr. Ge has, however, alleged next to no facts in support

of the proposition that Takeda's alleged misconduct resulted in the

submission of false claims or false statements material to false

claims for government payment.           Dr. Ge alleges a conclusion that

numerous claims for the four subject drugs would not have been

submitted for government payment but for Takeda's misconduct, but

alleges no more than that.             What is missing are any supporting

allegations upon which her conclusion rests and any particulars.

Dr. Ge's pleadings fall far short of what was found barely adequate

in Duxbury I, see 579 F.3d at 29-30, and are far less particular

                                       -15-
than those there whose sufficiency was deemed a "close call," id.

at 30.

            There, this court reversed the district court's dismissal

under Rule 9(b) of some of the relator's claims, reasoning that the

relator's identification of eight specific medical providers who

allegedly    submitted   false   claims,   plus   rough   time   periods,

locations, and amounts of the claims, and the specific government

programs to which the claims were made, were just enough to

constitute a pleading of fraud with particularity.          Id. at 30.4

Here, by contrast, Dr. Ge provided in response to the motions to

dismiss, at most, aggregate expenditure data for one of the four

subject drugs, with no effort to identify specific entities who

submitted claims or government program payers, much less times,

amounts, and circumstances.

            Dr. Ge thus made no attempt in her complaints to allege

facts that would show that some subset of claims for government

payment for the four subject drugs was rendered false as a result

of Takeda's alleged misconduct.      And any theory that all claims

submitted during this period were false has even less basis to

survive.    Dr. Ge attempts to satisfy the Rule 9(b) requirements

with a per se rule that if sufficient allegations of misconduct are

     4
         After discovery, those very claims were dismissed on
summary judgment as unsupported. United States ex rel. Duxbury v.
Ortho Biotech Prods., L.P., No. 03-12189-RWZ, 2012 WL 3292870 (D.
Mass. Aug. 13, 2012), aff'd, 719 F.3d 31 (1st Cir. 2013).

                                  -16-
made, it necessarily follows that false claims and/or material

false information were filed.             We reject that approach, which

violates the specificity requirements of Rule 9(b).

              On   appeal,   Dr.   Ge    articulates   three   new   theories

purporting to support the notion that all claims submitted during

the relevant period for the four subject drugs must have been

rendered false by Takeda's alleged misconduct; and that allegations

of falsity would per se suffice to constitute compliance with Rule

9(b).       All three theories are waived, however, not having been

raised properly before the district court.

              We do not rule on whether, had they not been waived, any

of these theories under any subsection would have added the needed

specificity under Rule 9(b), and merely say it is doubtful.5              See

Clausen, 290 F.3d at 1311 (commenting that Rule 9(b) does not

permit an FCA plaintiff "merely to describe a private scheme in

detail but then to allege simply and without any stated reason for

his belief that claims requesting illegal payments must have been

submitted, were likely submitted or should have been submitted to

        5
         We recognize that, under Allison Engine Co. v. United
States ex rel. Sanders, 553 U.S. 662 (2008), as construed in Gagne,
565 F.3d at 46 & n.7, the "presentment" requirement applies only to
her subsection (a)(1)(A) claims and not her subsection (a)(1)(B) or
subsection (a)(1)(C) claims. However, Rule 9(b)'s particularity
requirement applies with full force to all three subsections. See
Gagne, 565 F.3d at 42, 45. Here, Dr. Ge has not alleged in her
second amended complaints, with specificity, facts that comply with
Rule 9(b) as to any of her claims. In any event, as discussed
infra, her new theories of FCA liability were waived.

                                        -17-
the [g]overnment"); see also United States ex rel. Nathan v. Takeda

Pharm. N. Am., Inc., 707 F.3d 451, 457 (4th Cir. 2013) ("[We] hold

that when a defendant's actions, as alleged and as reasonably

inferred from the allegations, could           have led, but need not

necessarily have led, to the submission of false claims, a relator

must allege with particularity that specific false claims actually

were presented to the government for payment." (emphasis added));

United States ex rel. Atkins v. McInteer, 470 F.3d 1350, 1359 (11th

Cir. 2006) ("[Relator] has described in detail what he believes is

an elaborate scheme for defrauding the government by submitting

false claims. . . . [Relator] fails to provide the next link in the

FCA liability chain: showing that the defendants actually submitted

reimbursement claims for the services he describes.").

A.        Implied Warranty

          Dr. Ge's first additional theory of per se ineligibility

for federal reimbursement of all claims for the four drugs rests on

the assertion that the subject drugs were not "as safe as Takeda

purported them to be."      Dr. Ge contends that through labels and

participation   in   the   adverse    event   reporting   process,   Takeda

represented to all patients, doctors, and the government that the

subject drugs possessed certain risks and benefits.                  Dr. Ge

alleges, however, that the subject drugs "did not possess the

safety profile Takeda claimed they would."          And from this Dr. Ge

                                     -18-
infers that she has adequately stated that all claims submitted to

the government for those drugs were false.

             Dr. Ge's first theory is waived, having been raised only

in "cursory fashion" before the district court.         See Rodríguez v.

Municipality of San Juan, 659 F.3d 168, 175 (1st Cir. 2011) ("It

should go without saying that we deem waived claims not made or

claims adverted to in a cursory fashion, unaccompanied by developed

argument.").     Dr. Ge asserted to the district court only that

Takeda's alleged fraudulent conduct led to the submission of claims

that would not have otherwise occurred, without providing any

specificity, and alleging nothing more.          But that is inadequate;

courts should not be asked to guess the contents of a theory of

liability.      "[I]ssues   adverted   to   in   a   perfunctory   manner,

unaccompanied by some effort at developed argumentation, are deemed

waived." United States v. Zannino, 895 F.2d 1, 17 (1st Cir. 1990).

             Dr. Ge did offer a bit more argumentation in her Rule

59(e) motion for reconsideration.         That was too late.       "To the

extent that appellants' reconsideration motion sought to raise an

argument waived at the trial stage, it must necessarily fail."

DiMarco-Zappa v. Cabanillas, 238 F.3d 25, 34 (1st Cir. 2001).

B.           "Reasonable and Necessary"

             Dr. Ge on appeal invokes 42 U.S.C. § 1395y(a)(1)(A),

which prohibits Medicare payments for treatments that are not

                                 -19-
"reasonable and necessary."6 According to Ge, as a result of

Takeda's alleged misconduct, certain reimbursement claims were

rendered   false   under   the   FCA   because   they   impliedly   --   and

incorrectly -- certified that the subject drugs were "reasonable

and necessary."

           No such theory was properly presented to the district

court before dismissal.      Dr. Ge concedes that she did not cite or

discuss 42 U.S.C. § 1395y(a)(1)(A) before the district court in her

memorandum in opposition to Takeda's motions to dismiss.             Dr. Ge

did provide a bare citation of § 1395y(a)(1)(A) in her second

amended complaints.        However, Dr. Ge did not allege in those

complaints that Takeda's alleged misconduct rendered claims for the

four subject drugs "[un]reasonable" or "[un]necessary."             Nor did

she make any effort to explain why that would be so.           See Pan v.

Gonzales, 489 F.3d 80, 87 (1st Cir. 2007) ("We long have held that

legal theories advanced in skeletal form, unaccompanied by some

developed argumentation, are deemed abandoned.").

C.         "Misbranded"

           On appeal Dr. Ge newly argues that false claims must have

been submitted to the government for the four drugs on the theory

that Takeda's failure to properly update the subject drugs' labels

     6
        Various state statutes and regulations governing Medicaid
reimbursement impose similar restrictions. See, e.g., 130 Mass.
Code Regs. 450.204 ("The MassHealth agency will not pay a provider
for services that are not medically necessary . . . .") (emphasis
added).

                                   -20-
caused those drugs to be "misbranded" for purposes of the federal

Food, Drug, and Cosmetics Act ("FDCA"), 21 U.S.C. § 352(a), and so

they were ineligible to enter interstate commerce, id. § 331(a).

Consequently, she now says they were ineligible for reimbursement.

At best, there was a gesture to Dr. Ge's "misbranding" theory

before the trial court, and it is waived.

              Dr.   Ge   rejoins   that   she   did    adequately    raise   a

"misbranding" argument before the district court.                 Her second

amended complaints alleged that Takeda failed to update the label

for Actos to accurately reflect the drug's risks, as required by

the FDCA.     However, as to ineligibility, Dr. Ge's complaints state

only: "[The FDCA] forbids 'misbranding' and provides a range of

civil   and    criminal    enforcement    mechanisms    against     inaccurate

product labeling."        Dr. Ge made no mention of ineligibility for

interstate commerce, let alone of ineligibility for reimbursement

on that basis.       At most, a footnote in her memorandum opposing

dismissal referred to misbranding but nothing more.            The argument

was waived.     See City of Bangor v. Citizens Commc'ns Co., 532 F.3d
70, 95 n.11 (1st Cir. 2008) (deeming waived argument "presented

only in a passing fashion in a footnote").                 The mention of

misbranding in Dr. Ge's Rule 59(e) motion was too little, too late.

See Cochran v. Quest Software, Inc., 328 F.3d 1, 11 (1st Cir. 2003)

("Litigation is not a game of hopscotch.         It is generally accepted

that a party may not, on a motion for reconsideration, advance a

                                     -21-
new argument that could (and should) have been presented prior to

the district court's original ruling.").

             To sum up: Dr. Ge waived all of her new arguments to the

effect that the four subject drugs were per se ineligible for

government    reimbursement    during    the    relevant    period   on   these

varying theories.        Dr. Ge's claims on all theories which were

presented fail under Rule 9(b).

                                   III.

             This court reviews the district court's denial of an

appellant's motion to amend and for reconsideration for abuse of

discretion.    Fábrica    de   Muebles   J.J.    Álvarez,    Incorporado     v.

Inversiones Mendoza, Inc., 682 F.3d 26, 31 (1st Cir. 2012);

Torres-Alamo v. Puerto Rico, 502 F.3d 20, 25 (1st Cir. 2007).

             Dr. Ge argues that she could have cured any defects in

her complaints had she been provided with leave to amend the two

times she asked.         She had already twice amended both of her

complaints in the 21 months after the filing of her initial

complaint.     The first request, after Takeda filed its motion to

dismiss in 2012, was in her memorandum in opposition to Takeda's

motion to dismiss and conditionally did state that if the court was

inclined to dismiss, then she would like to amend.7             The district

     7
       There, Dr. Ge's conditional request to amend consisted just
of two sentences:
          If the Court were to determine that Relator's
     Complaints are deficient in any regard, Relator
     respectfully requests that this Court afford her an

                                   -22-
court did not explicitly discuss the request, but did discuss the

additional appended material on Actos and said it did not cure the

deficiencies in the pleading.

          The second of her requests came in the form of a motion

to amend, filed post-judgment on November 29, 2012 in conjunction

with her motion for reconsideration under Rule 59(e) of the

judgment of dismissal.    The district court dismissed this late

motion without opinion in its December 18, 2012 order.

          When a motion to amend is properly made before entry of

judgment, the district court is to evaluate that motion under the

"liberal standard of Fed. R. Civ. P. 15(a)."    Palmer v. Champion

Mortg., 465 F.3d 24, 30 (1st Cir. 2006). "Amendments may be

permitted pre-judgment, even after a dismissal for failure to state

a claim, and leave to amend is 'freely given when justice so

requires.'"   Id. (quoting Fed. R. Civ. P. 15(a)).   The "request"

was not properly made.

          By contrast, as to post-judgment motions "a district

court cannot allow an amended pleading where a final judgment has

     opportunity to amend her complaint. Federal Rule
     of Civil Procedure 15(a) provides that leave to
     amend a pleading "shall be freely given when
     justice so requires," and reflects a liberal
     amendment policy.    O'Connell v. Hyatt Hotels of
     P.R., 357 F.3d 152, 154 (1st Cir. 2004); Rost, 507
F.3d at 733-34 (same); see also Foman v. Davis, 371
U.S. 178, 182 (1962) (leave to amend should be
     "freely given").

                                -23-
been rendered unless that judgment is first set aside or vacated

pursuant to Fed. R. Civ. P. 59 or 60."   Maldonado v. Dominguez, 137
F.3d 1, 11 (1st Cir. 1998).       "The granting of a motion for

reconsideration is 'an extraordinary remedy which should be used

sparingly.'"    Palmer, 465 F.3d at 30 (quoting 11 Charles Alan

Wright et al., Federal Practice and Procedure § 2810.1 (2d ed.

1995)).   The moving party "must 'either clearly establish a

manifest error of law or must present newly discovered evidence.'"

Marie v. Allied Home Mortg. Corp., 402 F.3d 1, 7 n.2 (1st Cir.

2005) (quoting Pomerleau v. W. Springfield Pub. Schs., 362 F.3d
143, 146 n.2 (1st Cir. 2004)).        A motion for reconsideration

"certainly does not allow a party to introduce new evidence or

advance arguments that could and should have been presented to the

district court prior to the judgment." Aybar v. Crispin–Reyes, 118
F.3d 10, 16 (1st Cir. 1997) (quoting Moro v. Shell Oil Co., 91 F.3d
872, 876 (7th Cir. 1996)).

          Dr. Ge relies on Foman v. Davis, 371 U.S. 178 (1962),

which stated:

          Of course, the grant or denial of an
          opportunity to amend is within the discretion
          of the District Court, but outright refusal to
          grant the leave without any justifying reason
          appearing for the denial is not an exercise of
          discretion; it is merely abuse of that
          discretion and inconsistent with the spirit of
          the Federal Rules.

Id. at 182.     Dr. Ge contends that the district court's denials

without a statement of reasons for her two requests amounted to

                               -24-
just the sort of "outright refusal . . . without any justifying

reason" that Foman proscribes.

          As   explained   in   Silverstrand   Investments    v.   AMAG

Pharmaceuticals, Inc., 707 F.3d 95, 107-08 (1st Cir. 2013), where,

as here, a request to file an amended complaint consists of nothing

more than "boilerplate sentences stating the well-settled 'freely

given' standard under which a request for leave to amend is

generally analyzed," a district court "act[s] well within its

discretion when completely disregarding the request."8       Indeed, in

Gray v. Evercore Restructuring LLC, 544 F.3d 320 (1st Cir. 2008),

a case involving a nearly identical request, this court explained

that except perhaps in "exceptional circumstances," a bare request

in an opposition to a motion to dismiss does not constitute a

motion to amend for purposes of Rule 15(a).    Id. at 327 ("Although

a court's denial of a motion to amend is typically reviewed for an

abuse of discretion, in this case the district court neither

granted nor denied a motion to amend. . . .    As [plaintiff] failed

to request leave to amend, the district court cannot be faulted for

failing to grant such leave sua sponte."); accord Fisher v. Kadant,

     8
        Dr. Ge argues that Silverstrand is inapposite because her
post-dismissal request for leave to amend consisted of several
pages of argument and was accompanied by two proposed amended
complaints and statistical and anecdotal evidence of the effects of
Takeda's alleged misconduct. Dr. Ge's second request is neither
here nor there with respect to whether the district court's
rejection of her first, "boilerplate" request amounted to an abuse
of discretion.

                                 -25-
Inc., 589 F.3d 505, 509-10 (1st Cir. 2009).               And even at that,

Foman     identifies   "repeated   failure   to    cure    deficiencies    by

amendments previously allowed" as reason for denying a motion for

leave to amend under the permissive Rule 15(a) standard. 371 U.S.

at 182.

             There was also no abuse in denying Dr. Ge's second

request.    It came after judgment, when the liberal leave to amend

language of Rule 15(b) does not apply.       Id.    In order to grant Dr.

Ge's second request, the district court would have had first to set

aside its judgment pursuant to Dr. Ge's motion to reconsider under

Rule 59(e).    It did not and did not abuse its discretion.

             Her argument, in any event, has no legs.          Dr. Ge could

hardly contend that the so-called "newly discovered evidence"

accompanying her second request was "not previously available."

Palmer, 465 F.3d at 30.     Dr. Ge could have sought the testimony of

an expert witness and/or subject drug users much earlier.                 Nor

could Dr. Ge plausibly identify some "manifest error of law"

committed by the district court.      Id.

             The district court's dismissal order identified the

evidentiary defects in Dr. Ge's complaints after Dr. Ge had twice

amended her complaints and after having considered arguendo Dr.

Ge's contested declaration and accompanying expenditure data.             As

this court has stated previously:

             To require the district court to permit
             amendment here would allow plaintiffs to

                                   -26-
             pursue a case to judgment and then, if they
             lose, to reopen the case by amending their
             complaint to take account of the court's
             decision. Such a practice would dramatically
             undermine the ordinary rules governing the
             finality of judicial decisions, and should not
             be sanctioned in the absence of compelling
             circumstances.

James v. Watt, 716 F.2d 71, 78 (1st Cir. 1983) (Breyer, J.).      So

too, here.

                                  IV.

             We affirm the district court's orders dismissing relator

Dr. Ge's claims and denying leave to amend her second amended

complaints.     Costs are awarded to Takeda.

                                 -27-