Giesse v. Secretary, Department of Health and Human Services

Raymond Giesse (plaintiff) suffered a stroke and received rehabilitative daily therapy at Aristocrat Berea, a skilled nursing facility (SNF). Giesse was enrolled in Kaiser Medicare+Choice Plan (M+C), under which Kaiser, a private insurer, contracted with the federal government to provide Medicare benefits. After two weeks of SNF care, Giesse was notified in writing that his Medicare SNF care benefits would be terminated. Giesse was informed of his right to appeal. Without appealing, Giesse sold his house under market value and used the sale proceeds to move into an assisted-living facility. Giesse did not receive any SNF care after leaving Aristocrat Berea. Approximately two months later, Giesse petitioned Kaiser to reconsider the discontinuation of SNF care coverage. However, rather than petitioning for reinstatement of SNF care coverage, Giesse sought monetary damages. Kaiser denied the request for reconsideration. Kaiser then submitted the claim to an independent healthcare dispute resolution agency, which dismissed Giesse’s claim, holding that it was a grievance and not an appeal for medical coverage. Both the administrative-law judge (ALJ) and the Medicare Appeals Council (MAC) affirmed the dismissal on appeal. Giesse then appealed to the district court and raised additional tort and constitutional claims. The district court dismissed Giesse’s claim for lack of subject-matter jurisdiction. Giesse appealed.