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United States v. Paulus

United States Court of Appeals for the Sixth Circuit

April 26, 2018, Argued; June 25, 2018, Decided; June 25, 2018, Filed

File Name: 18a0121p.06

No. 17-5410


 [*270]  [***2]   McKEAGUE, Circuit Judge. Mark Twain once quipped that "there are three kinds of falsehood: lies, damnable lies, and statistics." Dr. Paulus begs to differ and insists that certain statistical estimations cannot be false. As a cardiologist, Paulus [**2]  interpreted hundreds of angiograms—specialized x-rays that approximate how severely a person's arteries are blocked. A federal jury convicted him of committing healthcare fraud and making false statements, on the theory that he exaggerated the extent of blockages (e.g., noting 80% blockage instead of 30%), so he could perform and bill for unnecessary procedures. The district court entered a judgment of acquittal and conditionally granted a new trial, reasoning that angiogram interpretations are not facts subject to proof or disproof. Because angiogram interpretations cannot be false, the reasoning goes, Paulus could not have lied. We disagree with this premise, and accordingly REVERSE the judgment of the district court and REMAND for further proceedings.

Heart diseases are a leading cause of death in the United States. One major  [*271]  contributor to these ailments is the narrowing of coronary arteries near the heart due to fatty plaque buildup. This case revolves around how doctors measure the severity of that blockage.

The arteries near a person's heart gradually narrow as a consequence of aging. An artery becomes narrower as fatty plaque and cholesterol accumulate on the inside of the [**3]  artery wall. The medical term for this process is "stenosis." Stenosis itself is neither medically significant nor dangerous—many middle-aged people have some level of stenosis that does not impede the heart's ability to pump blood to the body. Problems arise when stenosis becomes more severe. If the artery becomes too narrow, it tends to restrict the amount of blood flowing back into the heart. This can trigger chest pain or pressure, which in turn should prompt a visit to the doctor. If ignored or left untreated, the plaque buildups can rupture and form a clot that completely  [***3]  blocks blood flow into the heart. The patient then experiences a heart attack, which can quickly be fatal.

No one wants to risk a heart attack. But diagnosing the source of chest pain is complicated and difficult, even for seasoned doctors. There are plenty of other cardiac (and non-cardiac) conditions that can mimic the symptoms of severe stenosis. To promote accurate diagnosis and effective treatment, the medical field has developed a battery of tests, each with their own advantages and disadvantages. These include noninvasive Electrocardiograms (EKGs) and Echocardiograms (ECHOs), which use electrical signals [**4]  and ultrasound waves to measure the heart's integrity. Invasive tests, such as Nuclear Stress Tests (NSTs), require injecting radioactive dye into the bloodstream and then using imaging software to observe blood flow through the cardiac system.

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894 F.3d 267 *; 2018 U.S. App. LEXIS 17149 **; 2018 FED App. 0121P (6th Cir.) ***; 106 Fed. R. Evid. Serv. (Callaghan) 919; 2018 WL 3097952

UNITED STATES OF AMERICA, Plaintiff-Appellant, v. RICHARD E. PAULUS, M.D., Defendant-Appellee.

Prior History:  [**1] Appeal from the United States District Court for the Eastern District of Kentucky at Ashland. No. 0:15-cr-0015-1—David L. Bunning, District Judge.

United States v. Paulus, 2017 U.S. Dist. LEXIS 32097 (E.D. Ky., Mar. 7, 2017)


angiograms, blockage, district court, stenosis, patients, stent, cardiologist, arteries, new trial, severe, blood, interpretations, recorded, images, weight of the evidence, tests, fraudulent intent, variability, witnesses, make a false statement, colleague, judgment of acquittal, enter a judgment, expert testimony, coronary artery, guilty verdict, heart attack, conditionally, convicted, Disease

Criminal Law & Procedure, Trials, Motions for Acquittal, Standards of Review, De Novo Review, Sufficiency of Evidence, Fraud Against the Government, False Statements, Elements, False Claims, Postconviction Proceedings, Motions for New Trial, Abuse of Discretion, New Trial, Evidence, Evidence, Authentication, Plain Error, Admissibility, Statements as Evidence, Compromise & Settlement Negotiations