                      RECOMMENDED FOR FULL-TEXT PUBLICATION
                           Pursuant to Sixth Circuit Rule 206
                                  File Name: 09a0410p.06

               UNITED STATES COURT OF APPEALS
                               FOR THE SIXTH CIRCUIT
                                 _________________


                                                X
                          Plaintiff-Appellee, -
 UNITED STATES OF AMERICA,
                                                 -
                                                 -
                                                 -
                                                      Nos. 06-3882/4206
           v.
                                                 ,
                                                  >
                                                 -
                       Defendant-Appellant. -
 JORGE A. MARTINEZ,
                                                 -
                                                N
                  Appeal from the United States District Court
                for the Northern District of Ohio at Youngstown.
                No. 04-00430—Donald C. Nugent, District Judge.
                                  Argued: June 16, 2009
                         Decided and Filed: December 1, 2009
                  Before: KEITH, COLE, and WHITE, Circuit Judges.

                                   _________________

                                       COUNSEL
ARGUED: Jonathan P. Witmer-Rich, FEDERAL PUBLIC DEFENDER’S OFFICE,
Cleveland, Ohio, for Appellant. Nina Goodman, UNITED STATES DEPARTMENT OF
JUSTICE, Washington, D.C., for Appellee. ON BRIEF: Jonathan P. Witmer-Rich,
FEDERAL PUBLIC DEFENDER’S OFFICE, Cleveland, Ohio, for Appellant. Nina
Goodman, UNITED STATES DEPARTMENT OF JUSTICE, Washington, D.C., for
Appellee.
                                   _________________

                                        OPINION
                                   _________________

        COLE, Circuit Judge. A jury convicted Defendant-Appellant Dr. Jorge A. Martinez
of eight counts of distribution of controlled substances, in violation of 21 U.S.C. § 841
(Counts 2-5, 7-8, and 10-11); fifteen counts of mail fraud, in violation of 18 U.S.C. § 1341
(Counts 13-27); ten counts of wire fraud, in violation of 18 U.S.C. § 1343 (Counts 28-37);
twenty-one counts of health care fraud, in violation of 18 U.S.C. § 1347 (Counts 38-58); and



                                             1
Nos. 06-3882/4206             United States v. Martinez                               Page 2


two counts of health care fraud resulting in the death of patients, in violation of 18 U.S.C.
§ 1347 (Counts 59-60). Martinez’s appeal is based on his claims that the evidence was
insufficient to support his conviction and that the district court’s admission of a video
portraying a non-witness physician performing medical procedures constituted reversible
error. Martinez also argues that his sentence is both procedurally and substantively
unreasonable. We AFFIRM.

                                   I. BACKGROUND

A. Factual Background

        Dr. Jorge A. Martinez, an anesthesiologist, operated a pain-management clinic in
Parma, Ohio. As part of his practice, Martinez regularly prescribed controlled substances
and administered injections to ease his patients’ pain and charged the cost of the
prescriptions and injections—billed as “nerve blocks”—to the patients’ private insurance
carriers, Medicaid, Medicare, or the Ohio Bureau of Workers’ Compensation (“BWC”)
(collectively “health care benefit programs”). The bills used standard billing codes to
identify the services for which Martinez requested compensation. Martinez generally
advised his patients to receive nerve-block injections every one to two weeks, and he wrote
his patients prescriptions for oral pain medication to use during the periods between
injections.

        The Federal Bureau of Investigation (“FBI”) began investigating Martinez for health
care fraud in the summer of 2002. At that time, as part of an unrelated investigation, the FBI
noticed that Martinez ranked the highest among Ohio medical practitioners in submitting
claims for reimbursement for certain procedures to Blue Cross/Blue Shield and that he
ranked well above his Ohio peers for billing codes for certain medical procedures. During
this period, the FBI also became aware that the Office of the Inspector General of the United
States Department of Health and Human Services had received a complaint from its
Medicaid unit regarding Martinez’s billing practices. FBI Agent Jennifer A. Boyer
thereupon began an investigation. As part of its investigation, the FBI enlisted one of
Martinez’s employees, Cindy Bayura, a nurse, to carry an audio-recorder for two days and
a video camera for eight days to capture covertly the interactions between Martinez and his
Nos. 06-3882/4206              United States v. Martinez                              Page 3


patients. Based on the evidence gathered, the Government obtained a search warrant for
Martinez’s files, arrested him, and indicted him.

        The Government’s theory at trial was that from about January 1998 until September
2004, Martinez engaged in fraud and endangered his patients by omitting physical
examinations, ignoring “red flags” of painkiller addiction, giving appreciably more injections
than were medically necessary or advisable, and providing at-risk patients with treatments
that would leave them dependent on him for pain-suppressant prescriptions. According to
the Government, Martinez hinged patients’ receipt of oral pain medication prescriptions on
their willingness to visit his office and receive nerve-block injections, which Medicare,
Medicaid, and other insurance companies reimbursed at higher rates than other injections
and office visits. The Government also argued that Martinez’s fraud involved ignoring his
patients’ medical needs, resulting in the death of two patients.

        To support its theory at trial, the Government presented evidence that Martinez’s
administration of injections to patients far exceeded the number administered by other
pain-treatment doctors in Ohio. For example, the Government admitted BWC reports
showing that Martinez gave each patient an average of sixty-four nerve-block injections per
year, while the state average for pain-treatment patients was only 2.5 injections per year.
Also, on the days that patients received injections, Martinez gave his patients an average of
4.14 shots in one visit, while the statewide average was only 1.18. Additionally, the
Government presented evidence that Martinez did not inform patients of the “optional”
nature of the injections or of the potential risks and side effects.

        The Government’s evidence also established that Martinez saw many more patients
per day than other Ohio doctors, which, according to the Government’s theory, meant that
Martinez provided substandard medical care. According to sign-in sheets maintained at
Martinez’s offices and testimony from former employees, Martinez often saw well over 100
patients per day and, on average, around sixty patients during the eight-and-one-half hours
his office was open. At trial, members of Martinez’s staff testified that he frequently spent
only two to five minutes with patients during appointments and performed little or no
physical examination of patients during these brief visits, but Martinez billed the visits
under billing codes used for more extensive office visits. Relatedly, the jury heard evidence
Nos. 06-3882/4206              United States v. Martinez                               Page 4


that a doctor who was properly treating his patients for pain could not possibly see that
number of patients each day.

        The Government’s expert witness, Dr. Douglas Kennedy, a pain-management
specialist, reviewed the videos of office visits and the medical records for the patients named
in the indictment. He testified that Martinez’s billing to health care benefit programs was
“not appropriate in any fashion,” (Joint Appendix (“JA”) 1359), because the procedures and
office visits for which Martinez submitted bills “could not have been performed.” (JA
1359.) Moreover, even if the procedures were performed, “they were not medically
necessary in any way.” (JA 1359.) Dr. Kennedy further explained that the appropriate
medical practice for administering nerve-block injections allows for no more than “three
injections over three to six months” unless additional injections are “absolutely indicated and
everything else has been ruled out,” (JA 1303, 1305), but that Martinez routinely provided
as many as twenty injections to patients at their weekly or biweekly appointments.
Additionally, Dr. Kennedy concluded that Martinez’s prescriptions for controlled substances
could not have been for legitimate medical purposes and that such prescriptions were outside
the bounds of accepted medical practice. Because of all these factors, Dr. Kennedy testified
that Martinez and his patients did not have a true doctor–patient relationship.

        The jury also heard evidence that Martinez did not comply with accepted standards
of medical practice, including the Ohio State Medical Board’s guidelines for prescribing
controlled substances for intractable pain. Martinez’s patients likewise testified that he
prescribed high dosages of pain medications without any physical examination or discussion
of their symptoms. And another government expert witness, Dr. Theodore Parran, a
specialist in pain management and in the treatment of addiction, reviewed the files for those
patients named in the indictment and testified that Martinez prescribed medication for
patients he saw for only a few minutes and frequently ignored “red flags” indicating that a
patient’s drug use “was out of control.” (JA 2084-91, 2134-66.)

        The Government also argued that Martinez’s techniques were outside the bounds of
accepted medical practice. The jury was repeatedly shown videos of Martinez treating his
patients by walking into an exam room, with needle in hand, quickly “jabbing” the patient
and sometimes “twisting” the needle, then quickly leaving the room. Dr. Kennedy testified
Nos. 06-3882/4206               United States v. Martinez                               Page 5


that this technique, without any physical examination or the “palpatation of topical
landmarks,” made it impossible for Martinez to “know where the medicine [was] going,” and
Martinez could not have reached the nerves using such an unorthodox technique. (JA 1313-
14.) Dr. Kennedy also relied on a video of Dr. Mark Boswell administering nerve-block
injections to demonstrate the “proper” way to perform the medical procedures for which
Martinez billed.

          Finally, the Government presented evidence regarding several patients who it alleged
had died as a result of Martinez’s care, including detailed evidence about the circumstances
surrounding the deaths of two patients, John Lancaster and Blair Knight. The Government
presented evidence that Martinez’s course of treatment for these two patients led to their
deaths.

          In his defense, Martinez called several former employees and fifteen former patients,
all of whom testified that Martinez provided thorough and effective pain treatment. Martinez
also called Dr. Thomas Stinson, an anesthesiologist, as an expert witness, who testified that
the nerve-block injections performed by Martinez were within the bounds of accepted
medical practice.

B. Procedural Background

          Martinez was charged in a sixty-count indictment. The district court dismissed
Count 1 (conspiracy to distribute drugs) after all of the evidence had been submitted.
Following a week-long deliberation, on January 12, 2006, the jury acquitted Martinez on
Counts 6, 9, and 12—three of the twelve counts of distribution of controlled substances
outside the bounds of medical practice––and convicted him on all other counts. Martinez
filed motions for a judgment of acquittal, under Rule 29 of the Federal Rules of Criminal
Procedure, and for a new trial, under Rule 33 of the Federal Rules of Criminal Procedure.
The district court denied both motions. On June 14, 2006, the district court sentenced
Martinez to concurrent terms of 240 months in prison each on Counts 2-5, 7-8, 10-11 and
13-37, 120 months in prison each on Counts 38-58, and life imprisonment on Counts 59-60.

          Concluding that the calculation of restitution was complicated and required further
factfinding, the district court referred the matter to a magistrate judge. On August 23, 2006,
the district court adopted the magistrate judge’s Report and Recommendation as to the
Nos. 06-3882/4206             United States v. Martinez                                Page 6


amount of restitution to be paid by Martinez and entered its final judgment. Counsel for
Martinez filed a notice of appeal on August 30, 2006. The district court entered amended
judgments that altered the restitution calculation on October 12 and 13, 2006, setting the
final amount of restitution at $14,322,003.12. Martinez timely appealed.

                                      II. ANALYSIS

        Martinez makes four arguments on appeal. First, he argues that the district court
erred in admitting the video of Dr. Mark Boswell performing certain medical procedures on
the grounds that the video was inadmissible hearsay and that its admission violated
Martinez’s rights under the Confrontation Clause. Second, Martinez contends that the
evidence presented at trial was insufficient to sustain his convictions. Third, Martinez claims
that Dr. Parran’s expert testimony was inadmissible because it was mere speculation.
Finally, Martinez argues that his sentence is substantively and procedurally unreasonable.
We address each argument in turn.

A. Admissibility of the Boswell Video

        1. Inadmissible hearsay

        Martinez appeals his conviction on the ground that the district court erred in
admitting the video of Dr. Mark Boswell that Dr. Kennedy used during his testimony to
demonstrate the proper way to perform nerve-block injections. We review the district
court’s admission or exclusion of evidence under an abuse-of-discretion standard. See
United States v. Hunt, 521 F.3d 636, 642 (6th Cir. 2008) (citing United States v. Ganier, 468
F.3d 920, 925 (6th Cir. 2006)). However, “[i]n reviewing a [district] court’s evidentiary
determinations, this [C]ourt reviews de novo the court’s conclusions of law . . . and reviews
for clear error the court’s factual determinations that underpin its legal conclusions.” United
States v. McDaniel, 398 F.3d 540, 544 (6th Cir. 2005) (quoting United States v. Reed, 167
F.3d 984, 987 (6th Cir. 1999)). To the extent the district court’s admission of the Boswell
video constitutes an error of law, such error is an abuse of discretion. Id. (“[I]t is an abuse
of discretion to make errors of law or clear errors of factual determination.”).

        Turning to the video at issue, during her initial investigation of Martinez, Agent
Boyer contacted Dr. Boswell, the Chief of the Pain Clinic at University Hospital of
Nos. 06-3882/4206             United States v. Martinez                                 Page 7


Cleveland (“University Clinic”). She asked him whether the University Clinic’s library
contained any videos depicting the type of injections for which Martinez had billed third
parties. Because the library did not contain any such video, Dr. Boswell agreed to record
himself performing three types of nerve-block injection procedures on patients: a diagnostic
branch block (or facet injection), a transforaminal epidural steroid injection, and a
hypogastric plexus block. The video that Dr. Boswell recorded includes an audio track of
him communicating with patients and other University Clinic staff members, and the portion
of the video depicting a transforaminal epidural steroid injection includes textual phrases
superimposed on the screen. Some of the phrases are descriptive, like “Preparing a sterile
operative field”; while others are instructive, like “Continue proper needle placement in AP
view by injecting contrast agent.” Although Dr. Boswell did not appear as a witness during
the trial, the video of him performing the three procedures was admitted during Dr.
Kennedy’s testimony. The video was played in three segments, so that each procedure was
played in its entirety. After each segment, Dr. Kennedy explained the procedure, including
his views on how the procedure should be performed. After the second segment of the video
was played, Martinez’s counsel objected to the admission of the video on hearsay grounds.
The following colloquy occurred:

                Court: How is this admissible.
                [Government]: Because in aid of [Dr. Kennedy’s] testimony, he has
                reviewed these videos. He is familiar with this practitioner and has done
                tens of thousands of these procedures and would like to rely on this just as
                a textbook or any other material relied on by experts in the field to illustrate
                what these procedures are.
                Court: That’s an argument.
                [Defense Counsel]: And that’s why I would like to be heard. There is no
                foundation - - we don’t know if he is an expert, Judge.
                Court: [Dr. Kennedy] testified that he was. Do you know this Doctor who
                performed this?
                [Dr. Kennedy]: Yes, sir.
                Court: Is he an expert in the field?
                [Dr. Kennedy]: Yes.
                Court: And you recognize him as such?
Nos. 06-3882/4206             United States v. Martinez                                Page 8


                [Dr. Kennedy]: Yes.
                Court: And other people recognize him as such?
                [Dr. Kennedy]: Yes.
                [Defense Counsel]: But how do we get around hearsay, your Honor?
                Court: Objection is overruled.

(JA 1244-45.) After the Government played and Dr. Kennedy explained the second segment
of the video, Martinez’s counsel once again objected to the admission of the evidence. The
court again overruled the hearsay objection, and the Government played the third segment
of the video. Following Dr. Kennedy’s detailed medical explanation of the three procedures
demonstrated by Dr. Boswell, the Government showed videos of Martinez performing nerve-
block procedures. At one point, Dr. Kennedy explicitly compared Martinez’s performance
to Dr. Boswell’s performance: “Next, [Dr. Martinez] billed for [injections] like you saw Dr.
Boswell perform yesterday. [Dr. Martinez] performed two facet injections like you saw [Dr.
Boswell] perform . . . . [Dr. Martinez] did that in a span of about 20 seconds, billed $1,935,
and you saw how long he was in the room without examining the patient, with nonsterile
technique . . . . Need I say more?” (JA 1322.)

        On appeal, Martinez challenges both the verbal portions of the video and Dr.
Boswell’s nonverbal conduct on the video as impermissible hearsay. In conducting our
review, we must first determine whether the video constitutes a hearsay “statement” under
the Federal Rules of Evidence. The Federal Rules of Evidence define “hearsay” as “a
statement, other than one made by the declarant while testifying at the trial or hearing,
offered in evidence to prove the truth of the matter asserted.” Fed. R. Evid. 801(c). The
verbal portions of the video––both oral and written––easily satisfy the definition, but the
definition of statement also includes “nonverbal conduct of a person, if it is intended by the
person as an assertion.” Fed. R. Evid. 801(a); see also United States v. Sutton, 642 F.2d
1001, 1051 (6th Cir. 1980) (excluding defendants’ “nonverbal conduct showing possession
and distribution of a large volume of stolen merchandise” as impermissible hearsay). “The
key to the definition is that nothing is an assertion unless intended to be one.” Fed. R. Evid.
801(a) advisory committee’s note. Here, Dr. Boswell made the video in response to an FBI
request, with the purpose of demonstrating the proper performance of nerve-block injections.
Nos. 06-3882/4206             United States v. Martinez                               Page 9


Accordingly, because of Dr. Boswell’s intent, we conclude that his conduct during the
course of the video is an assertion of proper medical performance and is, therefore, a
statement under Rule 801(a) of the Federal Rules of Evidence.

        Because the video contains “statements,” we must next determine whether the
statements were offered for the “truth of the matter asserted.” Fed. R. Evid. 801(c). The
Government argues that the Boswell video was introduced for a non-hearsay purpose––to
assist the jury in understanding Dr. Kennedy’s testimony. Demonstrative evidence is
admissible to assist jurors in understanding basic principles. See, e.g., In re Air Crash
Disaster, 86 F.3d 498, 539 (6th Cir. 1996) (affirming admittance of video “to demonstrate
[a] circuit breaker’s inner workings,” in part, because “[u]se of the videotape was limited to
demonstration, and the court instructed the jury about the limited basis of its admission”).
In this case, however, the Government used the video for an additional purpose. The
Government’s opening statement and closing argument show that the Government intended
the video to demonstrate not only basic principles but the medically proper way to perform
nerve-block procedures––and to show that Martinez performed the injections improperly.
In its opening statement, the Government argued: “Jorge Martinez’s version of an epidural
will be shown to you, and also shown to you will be the University Hospital’s Pain
Management Clinic version of what an epidural really is, and you will see quite a
difference.” (JA 524.) Similarly, in closing argument, the Government referred to the
Boswell video, and stated that it “showed you how these shots are supposed to be given.”
(JA 526.) Dr. Kennedy used the video for the same purpose during his testimony. (See, e.g.,
JA 1260 (telling the jury that “[y]ou saw a lumbar trancoraminal procedure with Dr.
Boswell”).) Thus, the video was offered “for the truth of the matter asserted”—that the
procedures as performed in the video are properly performed, and that if Dr. Martinez’s
performance of those same procedures differed, it was improper. Accordingly, we conclude
that the video is hearsay.

        Of course, the video may still be admissible if it fits under one of the hearsay
exceptions. See, e.g., Fed. R. Evid. 803, 804, 807. The most relevant exception, the
“learned treatise” exception, provides:

                To the extent called to the attention of an expert witness upon
        cross-examination or relied upon by the expert witness in direct
Nos. 06-3882/4206              United States v. Martinez                                 Page 10


        examination, statements contained in published treatises, periodicals, or
        pamphlets on a subject of history, medicine, or other science or art,
        established as a reliable authority by the testimony or admission of the
        witness or by other expert testimony or by judicial notice. If admitted, the
        statements may be read into evidence but may not be received as exhibits.

Fed. R. Evid. 803(18) (emphasis added). At the outset, we note that we have not before
considered whether a video constitutes a “learned treatise.” In Constantino v. Herzog,
however, the Second Circuit reviewed the district court’s admission of a fifteen-minute
training video from the audiovisual library of the American College of Obstetricians and
Gynecologists. 203 F.3d 164, 168 (2d Cir. 2000). Both parties recognized that the video
was hearsay, but the district court found the video admissible under the “learned treatise”
exception. Id. at 168-69. The Second Circuit affirmed, holding that the video was a
“contemporary variant of a published treatise,” and “the video’s use as a training
resource––‘written primarily and impartially for professionals, subject to scrutiny and
exposure for accuracy, with the reputation [of its producers and sponsors] at stake’––is
clearly an important index of its authoritativeness.” Id. at 171, 173 (quoting Fed. R. Evid.
803(18) advisory committee’s note) (alteration in original). The court also acknowledged
that the video included recommendations culled from available literature and the video’s
narrator had “credentials which compared favorably with those of any expert who testified
at trial.” Id. at 173.

        The Boswell video does not have the same indicia of reliability as the training video
at issue in Constantino.      “[L]earned treatises usually have ‘sufficient assurances of
trustworthiness . . . . [A]uthors of treatises have no bias in any particular case . . . [and] are
acutely aware that their material will be read and evaluated by others in their field, and
accordingly feel a strong pressure to be accurate.’” In re Welding Fume Prods. Liab. Litig.,
534 F. Supp. 2d 761, 765 (N.D. Ohio 2008) (quoting 2 McCormick on Evidence § 321 (6th
ed. 2006)). In this case, the Boswell video was prepared for and given to the FBI for
litigation purposes, it was not subjected to peer review or public scrutiny, and it was not
“‘written primarily for professionals . . . with the reputation of the writer at stake.’”
Schneider v. Revici, 817 F.2d 987, 991 (2d Cir. 1987) (quoting the advisory committee’s
note accompanying Rule 803(18) to reject the application of the “learned treatise” exception
to video evidence). Because the Boswell video does not have the necessary qualities of
Nos. 06-3882/4206             United States v. Martinez                              Page 11


reliability, we do not need to decide whether a video could satisfy the “learned treatise”
exception—we simply conclude that the video in this case was impermissible hearsay.

        Having determined that the video was erroneously admitted, next, we ask whether
its admission was harmless error or whether it requires reversal of Martinez’s conviction.
In making this determination, we “must take account of what the error meant to [the jury],
not singled out and standing alone, but in relation to all else that happened . . . . In other
words, we must find that it was more probable than not that the error materially affected the
verdict.” United States v. Baker, 458 F.3d 513, 520 (6th Cir. 2006) (quoting United States
v. Pugh, 405 F.3d 390, 400-01 (6th Cir. 2005)). In determining whether such error has
occurred, we look to “the proceedings in their entirety, in the light of the proofs at trial.”
Beck v. Haik, 377 F.3d 624, 635 (6th Cir. 2004), overruled on other grounds by Adkins v.
Wolever, 554 F.3d 650 (6th Cir. 2009) (internal citations and quotation marks omitted).

        In this case, the video was used to bolster the testimony of the Government’s primary
expert and created a direct visual contrast between “proper” injections and the allegedly
“improper” injections Martinez performed. Although the video was admitted in error, we
conclude that the error did not materially affect the verdict given the remainder of the
evidence, including Dr. Kennedy’s opinions based on his own review of the Bayura
recordings and patient files. The jury heard evidence that the procedures for which Martinez
was billing required careful, precise placement of injection needles, and that such procedures
could not have been performed during the duration of his patients’ brief office visits. The
jury viewed multiple videos of Martinez quickly entering a room and injecting a patient or
repeatedly and rapidly injecting a patient. The jury also heard testimony that such
procedures did not constitute the billed-for procedures submitted to health care benefit
programs. Moreover, Dr. Kennedy and Dr. Parran both testified that, if performed, the
billed-for procedures were medically unnecessary and that Martinez’s prescribing practices
were outside the bounds of accepted medical practice. To counter this evidence, Martinez
presented the testimony of a single doctor, and that doctor did not say that Martinez was
performing the proper procedures during the videos. Thus, given the overwhelming
evidence that Martinez was not performing medically necessary procedures and that the
procedures were not those for which he was billing––and considering the weak evidence to
the contrary––we conclude that any error in admitting the Boswell video was harmless.
Nos. 06-3882/4206              United States v. Martinez                               Page 12


        2. Confrontation Clause

        On appeal, Martinez also challenges the admission of the Boswell video under the
Confrontation Clause of the Sixth Amendment. The Confrontation Clause states that “[i]n
all criminal prosecutions, the accused shall enjoy the right . . . to be confronted with the
witnesses against him.” U.S. Const. amend. VI. According to the Supreme Court in
Crawford v. Washington, “the Clause’s ultimate goal is to ensure reliability of evidence, but
it is a procedural rather than a substantive guarantee. It commands, not that evidence be
reliable, but that reliability be assessed in a particular manner: by testing in the crucible of
cross-examination.” 541 U.S. 36, 61 (2004); see also Melendez-Diaz v. Massachusetts, 129
S. Ct. 2527, 2536 (2009).

        Because of the importance of cross-examination, “[t]estimonial statements of
witnesses absent from trial have been admitted only where the declarant is unavailable, and
only where the defendant has had a prior opportunity to cross-examine.” Crawford, 541
U.S. at 59. This restriction applies to only statements that are “offered to prove the truth of
the matter asserted,” United States v. Gibbs, 506 F.3d 479, 486 (6th Cir. 2007), and it applies
whether or not the statement would otherwise be admissible under a hearsay exception. See
United States v. Hadley, 431 F.3d 484, 493-95 (6th Cir. 2005). Generally, asserted
violations of the Confrontation Clause are reviewed using the harmless-error analysis. Pugh,
405 F.3d at 400. In this case, however, Martinez did not object to the Boswell video on
Confrontation Clause grounds at trial, so we review his claim for plain error. Hadley, 431
F.3d at 498. To establish plain error, a defendant must show (1) that there was an
error—“some sort of deviation from a legal rule”; (2) that the error was “obvious, rather than
subject to reasonable dispute”; and (3) that the error affected the defendant’s “substantial
rights.” Puckett v. United States, 129 S. Ct. 1423, 1429 (2009) (internal quotation marks
omitted). “[I]f the above three prongs are satisfied,” we then have the “discretion to remedy
the error––which ought to be exercised only if the error seriously affect[s] the fairness,
integrity or public reputation of judicial proceedings.” Id. (alteration in original) (internal
quotation marks omitted). However, because we have already determined that any error in
the admission of the video was harmless and we would not exercise our discretion to remedy
any error here, Martinez cannot establish plain error. See United States v. Kingsley, 241 F.3d
828, 835-36 (6th Cir. 2001); United States v. Thomas, 11 F.3d 620, 630 (6th Cir. 1993).
Nos. 06-3882/4206             United States v. Martinez                              Page 13


B. Sufficiency of the Evidence

        Martinez also argues that the evidence is insufficient to support his convictions. In
particular, he contends that the evidence was insufficient to support his conviction for the
distribution of controlled substances outside the bounds of medical practice and for health
care, wire, and mail fraud because each patient listed in the indictment for those charges did
not testify, there was no audio or video evidence of those patients, there was no description
of Martinez’s treatment of those patients by government witnesses, and the names of those
patients were not mentioned during the testimony of the expert witnesses. He also argues
that the evidence was insufficient on the fraud counts based on nerve-block injections
because the Government’s case at trial focused solely on Martinez’s prescription practices,
not the nerve-block injections.

        In determining whether there is sufficient evidence to support a conviction, the
question before us is whether, “after viewing the evidence in the light most favorable to the
prosecution, any rational trier of fact could have found the essential elements of the crime
beyond a reasonable doubt.” Jackson v. Virginia, 443 U.S. 307, 319 (1979) (emphasis
omitted). In making this determination, we “reverse a judgment for insufficiency of
evidence only if [the] judgment is not supported by substantial and competent evidence upon
the record as a whole, [whether or not] the evidence is direct or wholly circumstantial.”
United States v. Stone, 748 F.2d 361, 363 (6th Cir. 1984). Moreover, “circumstantial
evidence alone can sustain a guilty verdict[, and it] need not remove every reasonable
hypothesis except that of guilt.” United States v. Hughes, 505 F.3d 578, 592 (6th Cir. 2007)
(emphasis omitted) (quoting Stone, 748 F.2d at 362).

        1. Counts 38-58: Health Care Fraud in Violation of 18 U.S.C. § 1347

        To obtain a conviction for health care fraud under 18 U.S.C. § 1347, the Government
is required to prove beyond a reasonable doubt that Martinez: “(1) knowingly devised a
scheme or artifice to defraud a health care benefit program in connection with the delivery
of or payment for health care benefits, items, or services; (2) executed or attempted to
Nos. 06-3882/4206                   United States v. Martinez                                        Page 14

                                                                                               1
execute this scheme or artifice to defraud; and (3) acted with intent to defraud.” Hunt, 521
F.3d at 645 (internal quotations omitted). After reviewing evidence adduced at trial in
the light most favorable to the Government, we conclude that a rational jury could have
found beyond a reasonable doubt that Martinez violated § 1347.

        First, we note that, contrary to Martinez’s argument, the lack of individualized
patient testimony for each count in the indictment alone does not render the evidence
before the court insufficient. See United States v. Clark, 26 F. App’x 422, 431 (6th Cir.
2001) (relying on expert testimony instead of patient testimony to establish health care
fraud under § 1347). If expert testimony is offered in lieu of patient testimony, the
expert testimony should be sufficiently specific to the patient, date, and services in the
indictment, but the patients’ names need not be specifically mentioned during the
expert’s testimony. Id.; cf. United States v. Tran Trong Cuong, 18 F.3d 1132, 1141 (4th
Cir. 1994) (finding evidence insufficient to support a doctor’s conviction on eighty
counts for drug distribution outside the usual course of medical practices and for other
than legitimate medical purposes where the convictions were based on a medical
expert’s summary report of thirty-three patient files that were not related to the patients
listed in the eighty-count indictment). Accordingly, we must determine whether the
evidence submitted is sufficient to support Martinez’s health care fraud conviction, even
though the Government did not offer individualized patient testimony.

        We conclude that substantial and competent evidence supports the conclusion
that Martinez executed a scheme to defraud a health care benefit program by the means
alleged (the second element of § 1347). The jury heard evidence that between 1998 and


        1
            18 U.S.C. § 1347 is titled “Health care fraud,” and states in relevant part:
                              Whoever knowingly and willfully executes, or attempts to execute, a scheme
                    or artifice - -
                                     (1)     to defraud any health care benefit program; or
                                      (2)       to obtain, by means of false or fraudulent pretenses,
                    representations, or promises, any of the money or property owned by, or under the
                    custody or control of, any health care benefit program,
                             in connection with the delivery of or payment for health care benefits, items,
                    or services, shall be fined under this title or imprisoned not more than 10 years, or both.
Nos. 06-3882/4206            United States v. Martinez                            Page 15


2004, Martinez obtained millions of dollars from Medicare, Medicaid, BWC, and private
insurers by submitting fraudulent claims for office visits and injections.            The
Government presented the billing codes that Martinez submitted for reimbursement for
each day listed in the indictment, the patients’ files, and testimony from Dr. Kennedy
that Martinez could not have conducted the number of procedures and consultations for
which he billed. The jury heard evidence that Martinez routinely saw more than sixty
patients, and often more than 100 patients in a day. Additionally, the jury reviewed
video and audio recordings that demonstrated the brief amount of time that Martinez was
physically present with each patient and heard testimony that the billing codes submitted
required a more thorough office visit than the recordings demonstrated. The jury also
heard testimony that Martinez’s jabbing techniques could not have possibly served as
legitimate injections. Moreover, Dr. Kennedy testified that Martinez’s prescription
practices for controlled substances was outside the bounds of accepted medical practice.
Last, the jury was presented with sufficient evidence to support an inference that
Martinez was perpetuating a fraud when he gave injections with such frequency. This
inference is supported by the testimony of Dr. Kennedy and Dr. Parran, who explained
that the frequency of injections was so high as to endanger the health of the patients.
Both physicians testified that the injections were performed as part of a “standard” rather
than an “individualized” treatment plan. The doctors also testified that many of the
injections for which Martinez billed were not performed, or, if performed, were not
medically necessary. Taken together, a jury easily could have inferred from this
evidence that the bills submitted were part of a scheme to defraud the medical benefit
programs. See United States v. Canon, 141 F. App’x 398, 405 (6th Cir. 2005)
(upholding doctor’s conviction under 18 U.S.C. § 1347 because government witness
testified that patient records did not support the doctor’s use of billing codes and “a
rational jury could infer a failure to perform from a failure to document”).

       Second, we conclude that there is sufficient evidence to support the jury’s
determination that Martinez knowingly devised a fraud scheme (the first element of
§ 1347) and that Martinez acted with the intent to commit fraud (the third element of
§ 1347). Martinez’s records for each patient named in the indictment and the claims that
Nos. 06-3882/4206                 United States v. Martinez                                        Page 16


Martinez submitted for reimbursement were admitted into evidence and available to the
jury for review. Dr. Kennedy testified that he reviewed the bills Martinez submitted and
his patient files, (JA 1266-68, 1274-78), and concluded that the billing was “not
appropriate in any fashion” and that the procedures claimed in the billing were “not
medically necessary in any way.” (J.A. 1359-60.) Considering the evidence that
Martinez performed procedures and prescribed medication that expert witnesses deemed
medically unnecessary, a rational jury could infer that Martinez knowingly devised a
billing scheme with the intent to defraud. We, therefore, conclude that there is sufficient
evidence to support Martinez’s conviction for health care fraud under 18 U.S.C. § 1347.

       2. Counts 13-37: Mail and Wire Fraud in Violation of 18 U.S.C. §§ 1341 and
       1343
       18 U.S.C. § 1341 prohibits the use of the mail to execute a scheme to defraud.2
To convict Martinez of mail fraud under 18 U.S.C. § 1341, the Government was
required to prove beyond a reasonable doubt: “(1) a scheme to defraud, and (2) [that
Martinez caused] the mailing of a letter, etc., for the purpose of executing the scheme.”
Pereira v. United States, 347 U.S. 1, 8 (1954); see also Bender v. Southland Corp., 749
F.2d 1205, 1215-16 (6th Cir. 1984). One “causes” the mails to be used where he or she
“does an act with knowledge that the use of the mails will follow in the ordinary course
of business, or where such use can reasonably be foreseen, even though not actually
intended.” Pereira, 347 U.S. at 8-9. “The federal statute prohibiting mail fraud parallels
section 1343.” United States v. Griffith, 17 F.3d 865, 874 (6th Cir. 1994) (citing 18
U.S.C. § 1343). Indeed, the elements of § 1341 and § 1343 are nearly identical. To
obtain a conviction under § 1343, the Government must prove beyond a reasonable
doubt: “(1) a scheme or artifice to defraud; (2) use of interstate wire communications in



       2
           18 U.S.C. § 1341, entitled “Frauds and swindles,” states in relevant part:
                             Whoever, having devised or intending to devise any scheme or artifice to
                  defraud, or for obtaining money or property by means of false or fraudulent pretenses,
                  representations, or promises . . . for the purpose of executing such scheme or artifice or
                  attempting so to do . . . knowingly causes to be delivered by mail or such carrier
                  according to the direction thereon, or at the place at which it is directed to be delivered
                  by the person to whom it is addressed, any such matter or thing, shall be fined under this
                  title or imprisoned not more than 20 years, or both.
Nos. 06-3882/4206                   United States v. Martinez                                       Page 17


furtherance of the scheme; and (3) intent to deprive a victim of money or property.”3
United States v. Daniel, 329 F.3d 480, 485 (6th Cir. 2003) (quoting United States v.
Prince, 214 F.3d 740,747-48 (6th Cir. 2000)). Moreover, the first element of each
section (scheme to defraud) parallels, in part, the first element of health care fraud under
§ 1347. See 18 U.S.C. § 1347.

        As we have already noted, the Government presented sufficient evidence from
which a rational jury could find the first element (a scheme to defraud) and the third
element (intent to defraud) of both mail and wire fraud. Thus, for purposes of
determining sufficiency of the evidence, we need only determine whether evidence
existed from which a rational jury could conclude that Martinez used the mail and wire
communications for each of the specified underlying fraud counts. See 18 U.S.C.
§§ 1341, 1343. We also note that Martinez does not challenge the sufficiency of the
evidence as to the second element of each crime—that he caused the allegedly fraudulent
bills to be mailed or transmitted by wire communications. As such, Martinez has
forfeited any challenge to the sufficiency of the evidence for this element. United States
v. Crozier, 259 F.3d 503, 517 (6th Cir. 2001) (citing United States v. Layne, 192 F.3d
556, 566 (6th Cir. 1999)) (noting that arguments not developed on appeal are deemed
forfeited). Accordingly, we conclude that there is sufficient evidence for a jury to
conclude that Martinez committed mail and wire fraud.




        3
            18 U.S.C. § 1343, entitled “Fraud by wire, radio, or television,” states in relevant part:
                                Whoever, having devised or intending to devise any scheme or artifice to
                    defraud, or for obtaining money or property by means of false or fraudulent pretenses,
                    representations, or promises, transmits or causes to be transmitted by means of wire
                    . . . in interstate or foreign commerce, any writings . . . for the purpose of executing
                    such scheme or artifice shall be fined under this title or imprisoned not more than 20
                    years, or both.
        Id.
Nos. 06-3882/4206                  United States v. Martinez                                       Page 18


         3. Counts 59 and 60: Health Care Fraud Resulting in Death in Violation of
         18 U.S.C. § 1347(2)
         Finally, Martinez appeals his conviction under 18 U.S.C. § 1347(2), which
contains enhanced penalties in the event that a doctor’s health care fraud results in the
death of a patient. Section 1347(2) states, in relevant part: “[I]f the violation results in
death, such person shall be fined under this title, or imprisoned for any term of years or
for life, or both.” As addressed above, there is sufficient evidence to support a rational
jury’s conviction of Martinez for health care fraud under § 1347. At trial, the
Government proceeded under the theory that Martinez’s prolonged fraudulent treatment,
rather than any single treatment or dose, resulted in John Lancaster’s and Blair Knight’s
deaths. Martinez, however, argues that the Government failed to show that a rational
jury could find that he caused their deaths. Thus, the standard of causation required to
show that such fraud “result[ed] in death” becomes important in determining whether
there is sufficient evidence to support Martinez’s conviction as to these two counts. This
is an issue of first impression in this Circuit.4

         a.       Required causation under 18 U.S.C. § 1347(2)

         Section 1347 does not indicate the level of causation required to support
application of its enhanced penalties, but other federal statutes elevate punishment when
certain willful crimes “result in death.” In particular, 18 U.S.C. § 242 allows for a life
sentence if death results from certain intentional civil rights violations. In United States
v. Marler, the First Circuit determinated that § 242’s requirement for enhanced
punishment is met when the defendant’s willful violation of the statute is a “proximate
cause” of the victim’s death, concluding that proximate cause can be demonstrated
where death was the “natural and foreseeable” result of the defendant’s conduct. 756
F.2d 206, 215-16 (1st Cir. 1985); see also United States v. Woodlee, 136 F.3d 1399,

         4
            Although we are the first circuit court to consider what level of causation is required under the
statute, the Eleventh Circuit has considered whether evidence sufficiently supported a conviction for health
care fraud “[resulting] in bodily injury or death” under 18 U.S.C. § 1347, see United States v. Merrill, 513
F.3d 1293, 1298-99 (11th Cir. 2008), and several district courts have examined whether allegations were
sufficient to support an indictment under that provision. See United States v. Salko, No. 1:07-CR-0286,
2008 U.S. Dist. LEXIS 65211, at *17 (M.D. Pa. Aug. 26, 2008); United States v. Mermelstein, 487 F.
Supp. 2d 242 (E.D.N.Y. 2007). However, none of those courts has specifically construed the meaning of
the “result[ed] in death” language.
Nos. 06-3882/4206            United States v. Martinez                             Page 19


1405 (10th Cir. 1998) (holding that “the bodily injury element of the felony crime is
satisfied if injury was a foreseeable result of the” defendants’ violation of 18 U.S.C.
§ 254(b)); United States v. Harris, 701 F.2d 1095, 1101 (4th Cir. 1983) (holding that the
“if death results” language of 18 U.S.C. § 241 requires only that death is foreseeable and
naturally results from violating the statute); United States v. Guillette, 547 F.2d 743, 749
(2d Cir. 1976) (holding that life imprisonment may be imposed if death results from
violations of 18 U.S.C. § 241 when the defendant’s violation of that statute is a
proximate cause of the victim’s death).

        Although we have not interpreted the “results in death” language of § 242, in
United States v. Wiegand, we interpreted what level of causation is required to show “if
bodily injury results” under 42 U.S.C. § 3631. No. 93-1735, 1994 U.S. App. Lexis
37209, at *7 (6th Cir. Dec. 22, 1994). Section 3631 imposes a maximum one-year
sentence for interfering with an individual’s housing rights “because of [the individual’s]
race.” 42 U.S.C. § 3631(a). If, however, bodily injury results, the offense becomes a
felony and is punishable for up to ten years in prison. Id. We upheld the enhanced
punishment because the bodily injury that occurred was the “natural and foreseeable”
result of the defendant’s violation of the statute. In coming to this conclusion, we
explained “[a] fundamental principle of criminal law”: “[A] person is held responsible
for all consequences proximately caused by his criminal conduct. Thus, where events
are foreseeable and naturally result from one’s criminal conduct, the chain of legal
causation is considered unbroken . . . .” Wiegand, 1994 U.S. App. Lexis 37209, at *7
(internal quotation omitted).

        Additionally, in determining that proximate cause was the appropriate causation
requirement under 18 U.S.C. § 242, the First Circuit in Marler reasoned that “[w]hen the
Congress provided that [a violation] resulting in death may be punished by life
imprisonment, we must consider it to have been fully cognizant of the principles of legal
causation.” 756 F.2d at 216. The same is true here. Congress was aware of principles
of legal causation when it determined that a health care fraud “violation [that] results in
death” warrants an enhanced penalty. See 18 U.S.C. § 1347. We also note that the
parties do not challenge the district court’s determination that proximate cause is the
Nos. 06-3882/4206                  United States v. Martinez                                       Page 20


appropriate standard of causation, and the jury instructions required the jury to find that
Martinez was the proximate cause of the death of the two patients in order to convict him
of health care fraud resulting in death.5 We therefore conclude that proximate cause is
the appropriate standard to apply in determining whether a health care fraud violation
“results in death.”

         b.       Sufficiency of the evidence to convict Martinez of health care fraud
                  “resulting in death”
         Martinez argues that there is insufficient evidence to conclude that he
proximately caused the deaths of Lancaster and Knight. As we have already determined,
the evidence sufficiently demonstrated that Martinez committed fraud when he treated
patients by hurriedly giving them injections and prescriptions rather than taking
sufficient time to provide his patients with individualized care; the issue of whether
Martinez was the proximate cause of his two patients’ deaths is a closer question. Our
decision, however, is guided by the deference we must give to the jury’s verdict. We
must review the relevant evidence in the light most favorable to the Government and
must affirm Martinez’s conviction if any rational trier of fact could find that he was the
proximate cause of Lancaster’s and Knight’s deaths. Jackson, 443 U.S. at 319. “This
standard is a great obstacle to overcome, and presents the appellant in a criminal case
with a very heavy burden.” United States v. Matthews, 298 F. App’x 460, 464 (6th Cir.
2008) (internal citations omitted). Thus, in undertaking our review of the jury’s finding
that Martinez was the proximate cause of the two patients’ deaths, we cannot “substitute
[our] judgment for that of the jury.” Id.




         5
            During the trial, the jury was instructed that to convict Martinez of health care fraud resulting
in death, it had to find that Martinez’s fraud was the “proximate or direct cause” of the two patients’
deaths. According to the instructions, “proximate or direct cause exists where the acts of the Defendant
in committing healthcare fraud in a natural and continuous sequence directly produces the deaths and
without which they would not have occurred.” (JA 807.) The court also explained that Martinez is not
responsible for the deaths of Lancaster and Knight if Martinez’s alleged commission of health care fraud
was a remote cause of their deaths, i.e., if “the result could not have been reasonably foreseen or
anticipated as being the likely cause of the deaths.” (JA 807-08.) The jury was further instructed that
proximate cause does not exist “when another’s act, which could not have been reasonably foreseen and
is fully independent of [Martinez’s] alleged healthcare fraud, intervenes and completely breaks the effect
of [Martinez’s] conduct.” (JA 808.)
Nos. 06-3882/4206            United States v. Martinez                             Page 21


        Our decision is also guided by the principles of proximate cause. “The concept
of proximate cause incorporates the notion that an accused may be charged with a
criminal offense even though his acts were not the immediate cause of the victim’s death
or injury.” Guillette, 547 F.2d at 749. “In many situations giving rise to criminal
liability,” the harm “is not directly caused by the acts of the defendant but rather results
from intervening forces or events.” Id. “Where such intervening events are foreseeable
and naturally result from [the defendant]’s criminal conduct,” the defendant is
“criminally responsible for the resulting harm.” Id.; see also Hoopengarner v. United
States, 270 F.2d 465, 469 (6th Cir. 1959) (holding defendant culpable for the “natural
and probable consequence[]” of his conduct). Therefore, even if Martinez did not intend
for his two patients to die, he can be held responsible for their deaths if there was
sufficient evidence that it “reasonably might or should have been foreseen . . . that [his
fraudulent conduct] would be likely to create a situation which would expose another to
the danger of . . . death.” Id.; see also Harris, 701 F.2d at 1102 (holding that “if death
results” requirement under § 241 satisfied because death was “a foreseeable and natural
result” of defendant’s actions).

                i. John Lancaster

        The evidence presented is sufficient for a rational jury to conclude that
Lancaster’s death was a reasonably foreseeable consequence of Martinez’s fraudulent
treatment. The evidence demonstrates that Martinez treated Lancaster nearly every week
from January 1999 until September 2001, providing him with excessive injections and
prescriptions, inadequately monitoring him, and failing to provide him with
individualized care. During this period of time, Lancaster’s health deteriorated from that
of a relatively healthy and well-adjusted, albeit injured, individual to a moody, abusive,
and angry individual who no longer worked. There was sufficient evidence for a rational
jury to infer that Martinez’s treatment of Lancaster enabled and exacerbated Lancaster’s
addiction to controlled substances. Moreover, Lancaster’s wife, Karen Lancaster,
testified that she told Martinez that Lancaster had become addicted to drugs and that
Martinez responded by becoming “defensive and very angry.”                  (JA 2380-83.)
Additionally, notes in Lancaster’s file indicated that Martinez’s staff was aware that
Nos. 06-3882/4206             United States v. Martinez                              Page 22


Lancaster was at risk of becoming an addict and that he had been dismissed as a patient
by other doctors because of his dependency on prescription drugs. One note in
Lancaster’s file indicated that he had either used or sold heroin, OxyContin, and Valium,
and another note on a patient sign-in sheet identified Lancaster as an addict. Even
Martinez’s own expert, Dr. Stinson, testified that such signals would lead any
“reasonable” doctor to cease providing drugs to Lancaster.

        Despite the warning signs, Martinez did not alter his treatment of
Lancaster––including the last time Martinez treated Lancaster. Lancaster’s wife testified
that on September 4, 2001, Lancaster had recently been released from jail, where he had
not taken any pain medication. She also testified that her husband was very weak and
had lost weight. At Lancaster’s last appointment with Martinez on September 5, 2001,
Lancaster was shaky, loud, and complaining of severe pain because he was suffering
withdrawal symptoms. Martinez provided Lancaster with prescriptions for Kadian,
Vicodin, and Valium, all of which Lancaster filled on that day. On the day before
Lancaster’s death, September 12, 2001, Martinez billed insurance carriers for twelve
injections to Lancaster, although it is not clear that the billed-for injections were actually
given on September 5, 2001. Additionally, Martinez submitted the standard report to
BWC for payment indicating that Lancaster had no complications from the injections,
made a good recovery, and was discharged in “good condition.”

        The record demonstrates, however, that Lancaster was in anything but “good
condition.” Records of Lancaster’s office visit show that Lancaster was loud and shaky,
that Martinez may have slapped Lancaster to calm him down, and that Lancaster took
a four-hour nap on the examination table following the injections. Less than thirty-six
hours after his appointment with Martinez, Lancaster was found unconscious, and he
died less than one week later from aspiration pneumonia caused by a drug overdose.
Lancaster’s urinary drug screen tested positive for opiates, which include Kadian and
Vicodin; and benzodiazepines, which include Valium and cocaine. There is also
evidence that Lancaster had ingested heroin and cocaine, but tests were inconclusive as
to what drugs actually killed him. However, hospital records indicate that, on the
afternoon before he was admitted, Lancaster told his wife that he took three Kadian pills
Nos. 06-3882/4206            United States v. Martinez                            Page 23


at once. Records also show that Lancaster filled his final Kadian prescription from
Martinez, and Lancaster had not received a Kadian prescription from any other physician
for two months before his death. In addition, Dr. Kennedy testified that Martinez’s
entire course of treatment of Lancaster was a “very strong factor” in Lancaster’s death,
and that at Lancaster’s last appointment, Martinez “sent him home with medications .
. . that contributed directly to his death.” (JA 1432-35.) Dr. Parran likewise concluded
that Martinez’s prescriptions were outside the bounds of medical practice and given for
no legitimate purpose.

       Viewing the evidence in the light most favorable to the Government, a rational
jury could have concluded that Lancaster’s death was a foreseeable result of Martinez’s
conduct.   Martinez over-prescribed controlled substances that led to Lancaster’s
addiction to narcotics, and Martinez continued to perform unnecessary injections and
prescribe harmful medications despite the presence of the clear “red flags” of escalating
addiction. A rational jury could have found that the evidence demonstrates the fraud for
which Martinez was convicted—providing poor, inattentive treatment while billing for
quality treatment and excessive, highly-reimbursed nerve-block injections and
prescriptions—proximately caused Lancaster’s death. Thus, there is sufficient evidence
for the jury to conclude that Lancaster’s death by overdose was a reasonably foreseeable
result of Martinez’s conduct. Cf. Merrill, 513 F.3d at 1298-99 (holding that although
patients had other illegal substances in their systems when they died, sufficient evidence
existed for a reasonable jury to conclude that the physician’s fraudulent prescriptions
caused their deaths because the additional drugs found in their system were the same
type as those prescribed by the physician).

       In an attempt to break the chain of causation, Martinez argues that Lancaster’s
use of illegal narcotics constitutes an intervening cause relieving Martinez of criminal
culpability. This argument fails. “An intervening act is a coincidence when the
defendant’s act merely put the victim at a certain place at a certain time, and because the
victim was so located it was possible for him to be acted upon by the intervening cause.”
Wayne R. LaFave, 1 Substantive Crim. L. § 6.4 (f)(3) (2d ed. 2008) (emphasis omitted).
But, “an intervening act may be said to be a response to the prior actions of the
Nos. 06-3882/4206           United States v. Martinez                            Page 24


defendant when it involves reaction to the conditions created by the defendant.” Id.
(emphasis omitted); Guillette, 547 F.2d at 749 (“The concept of proximate cause
incorporates the notion that an accused may be charged with a criminal offense even
though his acts were not the immediate cause of the victim’s death or injury.”).
Accordingly, where “intervening events are foreseeable and naturally result” from a
defendant’s criminal conduct, “the chain of legal causation [is] unbroken” and the law
“holds the [defendant] criminally responsible for the resulting harm.” Guillette, 547
F.2d at 749. Because “the perimeters of legal cause are more closely drawn when the
intervening cause was a matter of coincidence rather than response,” an unforeseeable
coincidence will break the chain of legal cause, but a response will only do so if it is
abnormal. LaFave, 1 Subst. Crim. § 6.4(f)(3).

       Here, Martinez was not convicted of being the immediate cause of his patients’
deaths but of fraudulently performing unnecessary medical services that led to his
patients’ deaths. The jury could have concluded that Martinez’s treatment enabled and
exacerbated Lancaster’s addiction, and that, given that addiction, the overdose was a
natural and reasonably foreseeable result. See LaFave, 1 Subst. Crim. § 6.4(h) (noting
that with respect to felony murder, “self-inflicted harms attributable to the victim’s
weakened condition[] are quite normal and thus do not break the causal chain”).
Moreover, the jury was given an intervening-cause instruction. They were instructed
that they could not convict Martinez if they found that the cause of the two patients’
deaths was reasonably foreseen and independent of Martinez’s alleged health care fraud.
We must presume that the jury followed the instructions unless we have evidence to the
contrary. See Washington v. Hofbauer, 228 F.3d 689, 706 (6th Cir. 2000). Because a
rational jury could have found that the addiction and overdose were sufficiently linked,
we must defer to the jury’s reasonable judgment that the chain of legal causation was not
broken. Our deferential standard of review requires that we not displace the jury’s
verdict when Lancaster’s actions as an addict cannot to be said to break the chain of
proximate causation. See Molton v. City of Cleveland, 839 F.2d 240, 248 (6th Cir. 1988)
(holding that suicide of prisoner in police custody was a foreseeable consequence under
Nos. 06-3882/4206           United States v. Martinez                            Page 25


the circumstances and, therefore, not an independent intervening cause breaking the
chain of proximate causation).

               ii. Blair Knight

       As with Lancaster, there is no evidence that a prescription written by Martinez
directly caused Knight’s death, but there is sufficient circumstantial evidence to allow
a rational jury to conclude that Martinez proximately caused his death. Before his death,
Knight was Martinez’s patient for sixteen months, and evidence supports a conclusion
that Martinez fraudulently treated Knight in a manner similar to that of other patients.
Evidence at trial demonstrated that, over the course of Knight’s treatment by Martinez,
Knight’s health deteriorated such that he was bloated, unresponsive, and immobile. As
with Lancaster, there were “red flags” that Martinez’s treatment was enabling and
exacerbating Knight’s addiction to controlled substances. There were notes in Knight’s
charts indicating that Martinez’s staff was aware of Knight’s addiction and that Knight’s
treatment was harming him, including notes that his speech was “slurred and slow,” that
Knight had trouble walking due to the lack of feeling in his leg, and that he was failing
to follow the doctor’s prescribing orders. A January 3, 2001, letter in Knight’s patient
file indicated that Knight was being treated at a drug rehabilitation facility. Moreover,
an August 29, 2000, note in Knight’s patient chart stated that Knight was taking “double
the number” of OxyContin pills that Martinez prescribed, and that his speech was
“slurred and slow”––indicating overuse of the drug. (JA 1446-47, 3625.) And, as with
Lancaster and Martinez’s other patients, there is no indication that Martinez provided
individualized treatment or appropriately responded to these red flags but, instead,
continued to provide Knight with prescriptions and injections.

       During the two weeks preceding Knight’s death, he twice visited Martinez in
extreme pain. Knight was so bloated that he could not wear socks or shoes and was
covered in a red rash. Nonetheless, Martinez’s office notes show that Knight received
the “standard treatment,” and the notes contain the same generic statements indicating
that all was going well. There is no evidence that Martinez altered his treatment of
Knight even though these were indications of drug misuse.        Knight died of a drug
Nos. 06-3882/4206            United States v. Martinez                           Page 26


overdose on the same day as his last visit with Martinez. Toxicology reports indicate
that Knight overdosed on OxyContin pills from an unknown source, as well as
hydrocodone and Valium. The jury heard evidence that when Knight was transported
to the hospital, he had green-colored medicine in his mouth and nose, and that
OxyContin tablets are green or bluish green. During that last office visit, Martinez
prescribed OxyContin and Endodan, and pharmacy records show that Martinez was the
only doctor who prescribed OxyContin to Knight shortly before his death.

       There is no definitive evidence that Martinez prescribed the drugs in Knight’s
system at the time of his death. Nonetheless, there is sufficient evidence that Martinez’s
overall course of treatment proximately caused Knight’s death. Dr. Kennedy testified
that Martinez’s entire course of treatment of Knight “contributed largely” to Knight’s
death. The jury heard evidence that Knight became addicted to narcotics as a result of
Martinez’s fraudulent prescriptions and injections. Dr. Kennedy suggested that Martinez
should have monitored Knight’s addiction and provided him with medication only under
the supervision of an addiction specialist. He also testified that Martinez continued to
feed Knight’s addiction in order to get Knight to “come in and get [billable] procedures.”
(JA 1457.) Similarly, Dr. Parran testified that “any reasonable physician should [have
known] that this patient has an addiction problem” and should have known that
continued prescriptions would create a risk of overdose. (JA 2118-19.) Based on this
evidence, a reasonable jury could have inferred that Martinez furthered Knight’s
addiction to advance his fraudulent billing scheme and that Knight’s subsequent misuse
of prescribed substances was a foreseeable result of that addiction. Viewing the
evidence in the light most favorable to the Government, a rational jury could have
concluded that Knight’s overdose was the reasonably foreseeable result of Martinez’s
conduct.

C. Admissibility of Dr. Parran’s testimony

       Related to the issue of causation, Martinez contends that the district court erred
in admitting testimony from Dr. Parran, an addiction specialist who teaches at Case
Western Reserve School of Medicine. Dr. Parran testified that the drugs prescribed by
Nos. 06-3882/4206            United States v. Martinez                             Page 27


Dr. Martinez caused the deaths of Lancaster and Knight. Martinez objected to Dr.
Parran’s testimony at trial, but the district court overruled the objection. On appeal,
Martinez argues that the court impermissibly allowed Dr. Parran to speculate as to the
causes of Lancaster’s and Knight’s deaths.

       We review the district court’s ruling admitting or excluding expert testimony
under an abuse-of-discretion standard. Kumho Tire Co. v. Carmichael, 526 U.S. 137,
142 (1999). Rule 702 of the Federal Rules of Evidence provides:

                If scientific, technical, or other specialized knowledge will assist
       the trier of fact to understand the evidence or to determine a fact in issue,
       a witness qualified as an expert by knowledge, skill, experience, training,
       or education, may testify thereto in the form of an opinion or otherwise,
       if (1) the testimony is based upon sufficient facts or data, (2) the
       testimony is the product of reliable principles and methods, and (3) the
       witness has applied the principles and methods reliably to the facts of the
       case.

Under Rule 702, the district court must examine the expert witness’s testimony for
reliability and relevance. Our review of the district court’s admission of expert
testimony must “focus, of course, [] solely on principles and methodology, not on the
conclusions that they generate,” Daubert v. Merrell Dow Pharms., Inc., 509 U.S. 579,
595 (1993), and we must confirm that the “factual underpinnings of the expert’s opinions
were sound,” Greenwell v. Boatwright, 184 F.3d 492, 498 (6th Cir. 1999). However,
“[v]igorous cross-examination, presentation of contrary evidence, and careful instruction
on the burden of proof are the traditional and appropriate means of attacking shaky but
admissible evidence.” Daubert, 509 U.S. at 596.

       At trial, Dr. Parran testified that Lancaster’s overdose resulted from medication
prescribed by Martinez, but on cross-examination he testified that he could not say
“beyond a reasonable doubt” that the medicine prescribed caused Lancaster’s death. (JA
2231.) With respect to Knight’s death, Dr. Parran testified that the prescription from
Martinez “directly and causally contributed,” such that “if it [had not] been for” that
prescription, Knight would not have overdosed. (JA 2219.) First, we observe that this
testimony was not admitted in error because it is more than the sort of “unsupported
Nos. 06-3882/4206              United States v. Martinez                          Page 28


speculation” that is prohibited, as it was based on Parran’s examination of the toxicology
reports and the patients’ files. See McLean v. 988011 Ontario, Ltd., 224 F.3d 797, 801
(6th Cir. 2000) (noting that an “expert’s conclusions regarding causation must have a
basis in established fact and cannot be premised on mere suppositions,” and if “based
on assumed facts, must find some support for those assumptions in the record”). Thus,
we conclude that Dr. Parran’s testimony was not admitted in error.

           Further, the jury was instructed to consider whether the “course of treatment”
proximately caused the deaths of Lancaster and Knight––not simply whether the oral
prescriptions themselves resulted in their deaths. Given the evidence from which a
rational jury could find that Martinez’s “course of treatment” proximately caused the
deaths of Lancaster and Knight, we also conclude that any error in admitting Parran’s
testimony was harmless. Baker, 458 F.3d at 520.

D. Sentencing

           1. Standard of review

           Martinez argues that his sentence was both procedurally and substantively
unreasonable and that the district court’s loss calculation used to set the appropriate
amount of restitution was not supported by the evidence. We review challenges to the
district     court’s   sentencing   determinations     for   reasonableness   under    an
“abuse-of-discretion standard.” Gall v. United States, 552 U.S. 38, 56 (2007); Rita v.
United States, 551 U.S. 338, 361 (2007); United States v. Booker, 543 U.S. 220, 261
(2005). The reasonableness inquiry has both procedural and substantive components.
United States v. Caver, 470 F.3d 220, 248 (6th Cir. 2007). Accordingly, “we must
‘consider not only the length of the sentence but also the factors evaluated and the
procedures employed by the district court in reaching its sentencing determination.’”
United States v. Moon, 513 F.3d 527, 539 (6th Cir. 2008) (quoting United States v.
Webb, 403 F.3d 373, 383 (6th Cir. 2005)).
Nos. 06-3882/4206            United States v. Martinez                            Page 29


        2. Procedural reasonableness

        Martinez contends his sentence is procedurally unreasonable because the district
court failed to: (1) explain the calculation of the United States Sentencing Guidelines
(“U.S.S.G.” or “Guidelines”) range, (2) address Martinez’s objections to the Guidelines
range as calculated in the Presentence Investigation Report (“PSR”), (3) consider the
18 U.S.C. § 3553(a) factors, and (4) explain the sentence imposed. Martinez also argues
that the district court improperly relied on the jury’s implied findings not contained in
the verdict. In our review of a sentence for procedural reasonableness, we must “ensure
that the district court committed no significant procedural error, such as failing to
calculate (or improperly calculating) the Guidelines range, treating the Guidelines as
mandatory, failing to consider the § 3553(a) factors, selecting a sentence based on
clearly erroneous facts, or failing to adequately explain the chosen sentence.” Gall, 552
U.S. at 51. “Our ‘reasonableness review focuses on the factors listed in § 3553(a), one
of which is the Sentencing Guidelines themselves.’” Moon, 513 F.3d at 539 (quoting
United States v. Duckro, 466 F.3d 438, 442 (6th Cir. 2006)).

        We may conclude that a sentence is unreasonable when the district court “fails
to ‘consider’ the applicable Guidelines range or neglects to ‘consider’ the other factors
listed in 18 U.S.C. § 3553(a), and instead simply selects what the judge deems an
appropriate sentence without such required consideration.” Moon, 513 F.3d at 539
(citing United States v. Jones, 489 F.3d 243, 250-51 (6th Cir. 2007)). The § 3553(a)
factors are:

                 (1) the nature and circumstances of the offense and the history
        and characteristics of the defendant; (2) the need for the sentence to
        reflect the seriousness of the offense, to promote respect for the law, and
        to provide just punishment for the offense; to protect the public from
        further crimes of the defendant; and to provide the defendant with needed
        educational or vocational training, medical care, or other correctional
        treatment in the most effective manner; (3) the kinds of sentences
        available; (4) the appropriate advisory guideline range; (5) any other
        pertinent policy statement issued by the Sentencing Commission; (6) the
        need to avoid unwarranted sentence disparities among defendants with
        similar records who have been found guilty of similar conduct; and
        (7) the need to provide restitution to any victims of the offense.
Nos. 06-3882/4206            United States v. Martinez                            Page 30


Caver, 470 F.3d at 248 (quoting 18 U.S.C. § 3553(a)). “[T]he district court need not
‘engage in a ritualistic incantation’ of the § 3553(a) factors,” but its decision should be
“sufficiently detailed to reflect the considerations listed in § 3553(a)” to permit
meaningful appellate review. Moon, 513 F.3d at 539 (quoting United States v. McBride,
434 F.3d 470, 474 (6th Cir. 2006)). “The district court’s [decision] must also provide
some indication that the court considered the defendant’s arguments in favor of a lower
sentence and the basis for rejecting such arguments.” Id. (citing Jones, 489 F.3d at
250-51).

       At the sentencing hearing, the district court made an “initial” finding that “there
is a total offense level of 43 with a Criminal History Category I,” and then explained the
sentences that this calculation “initially” allowed for under each of the counts. (JA 870.)
This calculation was the same as that reached in the PSR, a range to which Martinez
objected both in writing and at his sentencing hearing. According to the PSR, this
calculation was reached in the following manner: The base level offense was 7, 24
additional levels were added for a loss of more than $50 million, 2 additional levels were
added because the offense involved conscious or reckless risk of death, 2 additional
levels were added because the offense involved sophisticated means, 6 additional levels
were added because the offense involved 250 or more victims, 2 additional levels were
added because the victims were vulnerable, 4 additional levels were added because
Martinez was the organizer and leader of extensive criminal activity, and 2 additional
levels were added because Martinez was in a position of trust. This resulted in an
offense level of 49, which was adjusted downward to the maximum offense level of 43,
resulting in an advisory Guidelines sentence of life imprisonment.

       In his objections to the PSR, Martinez objected to this calculation for a variety
of reasons. However, at sentencing, his objection focused on the district court’s method-
of-loss calculation and the enhancement for vulnerable victims. Martinez’s brief
addresses only the district court’s calculation of loss. Therefore, Martinez has forfeited
any other challenge to the Guidelines calculation. Crozier, 259 F.3d at 517.
Nos. 06-3882/4206            United States v. Martinez                           Page 31


       a. Loss calculation

       Martinez argues that the court calculated the loss caused by his crimes
incorrectly. We disagree. As an initial matter, we note that the district court explained
the method used to calculate the loss caused by Martinez’s crimes, and we review a
district court’s calculation of the amount of loss for clear error. United States v.
Blackwell, 459 F.3d 739, 772 (6th Cir. 2006). In order to challenge this calculation,
Martinez must “carry the burden of demonstrating ‘that the court’s evaluation of the loss
was not only inexact but outside the universe of acceptable computations.’” United
States v. Raithatha, 385 F.3d 1013, 1024 (6th Cir. 2004), vacated and remanded on
other grounds, 543 U.S. 1136 (2005) (quoting United States v. Tardiff, 969 F.2d 1283,
1288 (1st Cir. 1988)). When determining the amount of loss for sentencing purposes,
“a defendant will be held accountable for the actual or intended loss to a victim,
whichever is greater, or a combination thereof.” Id. (citing United States v. Wade, 266
F.3d 574, 586 (6th Cir. 2001)); see also U.S.S.G. § 2B1.1, cmt. n.3(A)(ii). Moreover,
“[s]o long as the intended loss is supported by a preponderance of the evidence, the
district court may use it in reaching the appropriate offense level.” Raithatha, 385 F.3d
at 1024 (quoting United States v. Logan, 250 F.3d 350, 371 (6th Cir. 2001)). Following
a verdict, restitution is properly ordered in the full amount of each victim’s loss. See
18 U.S.C. § 3664(f)(1)(A). “The term ‘victim’ is defined as ‘a person directly and
proximately harmed by a defendant’s offense.’” Hunt, 521 F.3d at 648 (quoting
18 U.S.C. § 3663A(a)(2)).

       During the sentencing hearing, the court questioned the parties regarding loss
calculation.   Martinez argued that the amount would properly be calculated at
approximately $45,000 because that was the loss corresponding to the exact charges on
the indictment. The court, in turn, articulated the Government’s position and said that
“the treatment that was given” and “the bills that were either submitted or intended to
be submitted” by Martinez were not for medical treatment, and therefore all the bills that
Martinez submitted were “properly covered”in the calculation of intended loss. (JA
888.) The Government supplemented this explanation, noting that all of the fraud counts
included an allegation that Martinez “devise[d] a scheme to defraud,” and that the
Nos. 06-3882/4206            United States v. Martinez                             Page 32


Government presented proof that the scheme ran from January 1998 until September
2004. (JA 893-894.) Because the charges referred not only to the specific charges in the
indictment, but also to the entire scheme underlying the fraud, the total intended loss
connected to the wire and mail fraud was properly included, resulting in an actual loss
of more than $12,337,230 for payments actually made to Martinez and an intended loss
of $60,799,000 for bills submitted by Martinez. These calculations were supported by
the testimony of representatives from BWC, Medicare, and Medicaid concerning the
amounts Martinez billed them and the payments Martinez received; by the expert
testimony of statistician Dr. Michael Nowak, who presented these calculations during
trial; and by the testimony of Dr. Kennedy, who examined the patient files and bills
submitted by Martinez.

        “Because [the health care benefit programs] would not have paid for [the
procedures] but for the presence of [Martinez’s] signature on the orders, [Martinez] was
the direct and proximate cause of the harm suffered by those entities.” Hunt, 521 F.3d
at 648. Thus, the district court did not commit error when it accepted the reimbursement
amounts over the years which Martinez was committing the fraud when it ordered
restitution. Further, it is appropriate for the court to consider the nature of the fraud in
determining whether the loss amount should be limited to the specific losses testified to
or to an amount derived from the nature of the fraud. Id. (rejecting defendant’s argument
that only the specific amounts proven could be included in the loss calculation, and
accepting estimates for loss based on the Government’s sample and average figures
provided by the insurance companies). Because the district court did not err in including
the total amount of intended loss in its calculation, Martinez cannot show that the
calculation of loss was incorrect.

        b. The district court’s consideration of the 18 U.S.C. § 3553(a) factors

        The court also recognized that the Guidelines are advisory and noted that it had
reviewed all of Martinez’s objections to the PSR. Here, the district court gave both
parties an opportunity to argue for what they deemed an appropriate sentence—Martinez
argued for a sentence of “time served,” and the Government argued for a sentence within
Nos. 06-3882/4206            United States v. Martinez                           Page 33


the Guidelines. Following a lengthy presentation by the Government of documents in
support of a Guidelines sentence in this case, the district court gave Martinez an
opportunity to argue for a downward variance. Martinez asked the court not to impose
a “draconian” penalty and professed his innocence, arguing that his actions were merely
an attempt to relieve his patients’ pain. Martinez also disclaimed responsibility for the
deaths of Lancaster and Knight, contending that he was not responsible for their drug
overdoses. He further requested leniency, arguing that a lower sentence was warranted
based on his years of service to his patients and his status as a non-citizen.

       The record reflects that the district court considered and rejected Martinez’s
arguments. The court’s reasoning in doing so was “sufficiently detailed to reflect the
considerations listed in § 3553(a) and to allow for meaningful appellate review.” United
States v. Mayberry, 540 F.3d 506, 518 (6th Cir. 2008) (internal quotation marks
omitted). Although the court acknowledged that some patients were satisfied with the
care provided by Martinez, it found that he had hurt many more. In response to
Martinez’s argument that the Guidelines sentence was “draconian,” the court explained:

       [P]eople who were helpless came to [Martinez] as their last hope, and
       [he] didn’t treat them according to medical standards; [he] . . . continued
       their addiction to narcotic drugs, and [he] didn’t get them better; they
       only got worse. And during this course of treatment, at least two people
       died as a result of the fraud and distribution of drugs. That being the
       case, the sentences don’t seem to be draconian.

(JA 932.) The court also remarked, “the point is, [Lancaster and Knight] came, sought
treatment, and they were in desperation, and [] you continued to prescribe drugs that
would continue [their] downward spiral, that resulted in [their overdoses], and that’s why
you are responsible [for their deaths].” (JA 933-34.) Before announcing Martinez’s life
sentence, the court stated that it was relying on the findings that it had made under 18
U.S.C. § 3553(a). Although the district court did not address Martinez’s pleas for a
lower sentence based on his years of service to his patients and his status as a
non-citizen, its failure to do so is not procedurally unreasonable. See United States v.
Liou, 491 F.3d 334, 339 n.4 (6th Cir. 2007) (noting that “a district court’s failure to
Nos. 06-3882/4206            United States v. Martinez                             Page 34


address each argument [of the defendant] head-on will not lead to automatic vacatur”
(citing Rita v. United States, 551 U.S. 338, 358 (2007))).

        3. Substantive reasonableness

        In addition to procedural reasonableness, we must determine whether Martinez’s
sentence is substantively reasonable. United States v. Webb, 403 F.3d 373, 383 (6th Cir.
2005). A sentence may be substantively unreasonable where the district court “‘select[s]
the sentence arbitrarily, bas[es] the sentence on impermissible factors, fail[s] to consider
pertinent § 3553(a) factors or giv[es] an unreasonable amount of weight to any pertinent
factor.’” United States v. Collington, 461 F.3d 805, 808 (6th Cir. 2006) (quoting Webb,
403 F.3d at 383). We have held that sentences within a properly calculated Guidelines
range are afforded a rebuttable presumption of reasonableness, and the defendant bears
the burden of rebutting this presumption. Caver, 470 F.3d at 247 (citing United States
v. Williams, 436 F.3d 706, 708 (6th Cir. 2006)). Martinez has failed to rebut that
presumption, and we conclude that his sentence is substantively reasonable.

E.      Martinez’s Pro Se Claims

        Martinez raises a number of additional pro se claims, but we decline to address
them because he is represented by counsel. United States v. Howton, 260 F. App’x 813,
819 (6th Cir. 2008) (“We decline to address [the defendant’s pro se] arguments because
[the defendant] was represented by counsel in this matter.”). Even if we did address
such claims, they are without merit.

                                  III. CONCLUSION

        For the foregoing reasons, we AFFIRM Martinez’s conviction and sentence.
