When “Medically Unnecessary” Becomes a Federal Crime

What Physicians Should Understand About Medical Necessity as a Theory of Criminal Liability

A note for physician clients on how medical-necessity-based prosecutions work and where the real exposure lies

Every physician makes judgment calls about what a patient needs. A brace, a cardiac workup, a wound graft, a genetic test: these decisions turn on training, experience, and the individual patient in front of you. So it can be unsettling to learn that “medically unnecessary” has become one of the most common phrases in federal health care fraud indictments. When the government alleges that care was not necessary, it is not merely disputing a clinical call. It is building a criminal case.

This article explains how medical-necessity-based prosecutions actually work, what separates an aggressive clinical judgment from a chargeable offense, and why the cases that result in convictions almost always involve far more than a difference of medical opinion. The goal is not to alarm. It is to help you see where the genuine risk lies, so that ordinary practice is never mistaken for something it is not.

Why Medical Necessity Is Slippery to Begin With

Part of what makes this area uncomfortable is that “medical necessity” has no single, fixed definition. The federal health care fraud statutes do not define it. Insurers each define it their own way, often without making their internal criteria public, and frequently with an eye toward what they will pay rather than what a patient clinically requires. Federal programs describe it in broad, partly circular terms, and state Medicaid programs and private payers add still more variations.

Medical necessity is, at bottom, subjective, and its definition varies from payer to payer and program to program. That is precisely what makes it so challenging for healthcare providers: a physician trying to conform to the standard finds that there is no single standard to conform to. The same order may be considered necessary by one payer and unnecessary by another, and the criteria that drive those determinations are often unpublished. If reasonable physicians and even insurers cannot agree on a precise standard, there is a fair argument that the term is too indefinite to support criminal punishment, at least where the dispute is genuinely about clinical judgment. Courts continue to weigh versions of that argument. For a practicing Florida physician, though, the more practical point is this: the cases the government actually brings rarely sit on that contested line. They tend to involve conduct that no definition of medical necessity would protect.

What the Government’s Strongest Cases Actually Look Like

Across recent prosecutions, the convictions and the most serious charges share a common feature: the government alleged that the physician or other healthcare provider was not exercising clinical judgment at all. The medical necessity allegation is usually paired with evidence that no real evaluation occurred, that signatures were sold, or that diagnoses were fabricated to fit the billing. Three recent cases illustrate the pattern.

The signing nurse practitioner: United States v. Hernandez

Elizabeth Hernandez, a Florida nurse practitioner, was convicted after a 2023 jury trial in the Southern District of Florida (No. 1:22-cr-20152) and sentenced to 20 years. According to the Justice Department, she signed thousands of orders for orthotic braces and genetic tests for Medicare beneficiaries she never spoke to, examined, or treated. Telemarketing companies sent her pre-filled orders, and she signed them attesting she had examined the patients, sometimes having others sign her name. In 2020, the government says, she ordered more cancer genetic tests for Medicare beneficiaries than any provider in the country, and billed Medicare for office visits, at times exceeding 24 hours of visits in a single day.

Her case is now on appeal to the Eleventh Circuit (No. 24-10047), where oral argument was held on January 30, 2026, and a decision is pending. Notice what drove the conviction: not a contested judgment about whether a particular brace was warranted, but the absence of any patient encounter behind thousands of certifications.

The rubber-stamped cardiac screenings: United States v. Dr. Finkelstein

In June 2026, a federal grand jury in the Southern District of Florida indicted Dr. Jason Finkelstein, a cardiologist, on health care fraud and conspiracy charges (No. 26-CR-80123). These are allegations only, and Dr. Finkelstein is presumed innocent unless and until proven guilty. According to the indictment, companies he was associated with marketed “no-cost” cardiovascular screening to student athletes, sent sonographers to campuses to run the same panel of tests on nearly everyone, and assigned false diagnosis codes so the screenings could be billed to insurers as medically necessary diagnostic testing rather than non-covered screening.

The indictment alleges Dr. Finkelstein approved tests in seconds without meaningful review. In one instance described in the charging document, he allegedly accessed roughly 63 cardiovascular images for a student athlete, some flagged with possible abnormalities, and signed all of them as “normal” about eleven seconds later. That student later died, and the indictment alleges Dr. Finkelstein continued signing other students’ tests as normal without reviewing them. In a text quoted in the indictment, asked about a test his company routinely billed, he allegedly wrote, “I don’t read those.”

These allegations have not been proven, and Dr. Finkelstein is presumed innocent. But the indictment shows what transforms a medical necessity question into a fraud charge: the government alleges the review was a fiction, the diagnoses were invented to satisfy coverage rules, and the certifications were false.

The allografts on hospice patients: United States v. Yukee

Also in June 2026, a grand jury in the Southern District of Texas indicted Marizel Yukee (No. 4:26-cr-370) in connection with an alleged amniotic wound allograft scheme. These are allegations only, and Ms. Yukee is presumed innocent unless and until proven guilty. The indictment alleges that she and her co-conspirators caused medically unnecessary skin-substitute grafts to be applied to elderly Medicare beneficiaries, many of them terminally ill hospice patients, and paid and received kickbacks tied to the referrals and product purchases. The government alleges more than $906 million in claims to Medicare and TRICARE, of which more than $297 million was paid.

Again, these are allegations not yet proven, and Ms. Yukee is presumed innocent. However, the allegations provide important information about what draws prosecutors’ scrutiny. The medical necessity theory here does not rest on second-guessing a close call. It rests on applying expensive grafts to patients for whom, the government contends, healing was not the realistic goal, paired with kickbacks that themselves taint the claims.

The Common Thread: It Is Rarely About Judgment Alone

Read together, these cases carry a reassuring message alongside the cautionary one. The government’s medical necessity prosecutions are not, as a rule, built on punishing doctors for honest clinical disagreements. They are built on one or more of the following: certifications signed without any patient encounter; diagnoses fabricated to meet coverage criteria; review that was a formality measured in seconds; volumes that no honest practice could generate; and kickbacks that corrupt the decision to order in the first place.

Where those features are present, the vagueness of “medical necessity” offers little protection. Where they are absent, and the question is truly one of clinical judgment, the physician’s exposure is far lower and the defenses far stronger.

What Tends to Draw Scrutiny

In the government’s enforcement pattern, certain features attract attention and invite a closer look. None is proof of wrongdoing, and each can be explained on the right facts, but recognizing them lets you examine your own practice before anyone else does:

1. Volume that makes you a statistical outlier for a given code, test, or device.
2. Orders or certifications generated from leads supplied by marketers, call centers, or sales reps rather than from your own patients.
3. Identical testing or equipment ordered across nearly every patient regardless of presentation.
4. Diagnosis codes that appear selected to unlock coverage rather than to describe the patient.
5. Review or sign-off so fast that meaningful evaluation would be impossible.
6. Any compensation tied to the volume or value of what you order or certify.

Good Clinical Practices = Strong Defense

The same record-keeping habits that support good care also support a strong defense if medical necessity is ever questioned. Contemporaneous documentation of the clinical reasoning behind an order, made at the time of service, is the single most valuable protection. A genuine evaluation appropriate to the complaint, certifications that are literally accurate about what you did, and compensation tied to your clinical time rather than to order volume all keep ordinary practice clearly on the right side of the line. When your records show why you reached a judgment, a medical necessity dispute stays what it should be: a clinical question, not a criminal one.

How The Baez Law Firm Can Help in Florida

The Baez Law Firm defends Miami physicians and other healthcare providers in federal and state health care fraud matters, including prosecutions built on allegations of medically unnecessary care, false certifications, and kickbacks. We have represented clients accused of healthcare fraud schemes alleged to involve hundreds of millions of dollars, and we understand both the government’s medical necessity theories and the clinical realities those theories can overlook.

If you have received an audit, a Civil Investigative Demand, a subpoena, a records request, or any contact from federal investigators concerning the medical necessity of your orders or services, the most important step is to involve experienced counsel before you respond. To discuss a matter in confidence, contact Kirsten R. Nelson at knelson@baezlawfirm.com.

This article is provided for general informational purposes and does not constitute legal advice or create an attorney-client relationship. The Hernandez matter is described based on the U.S. Department of Justice’s public statements and the appellate record and remains pending on appeal. The Finkelstein and Yukee matters are described based on grand jury indictments; the charges are allegations only, and each defendant is presumed innocent unless and until proven guilty beyond a reasonable doubt. Physicians with questions about a specific matter should seek advice from qualified counsel.