United States v. Paul Boccone

UNPUBLISHED

UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT

No. 12-4949

UNITED STATES OF AMERICA,

Plaintiff - Appellee,

v.

PAUL PHOTIADIS BOCCONE,

Defendant - Appellant.

No. 12-4952

UNITED STATES OF AMERICA,

Plaintiff - Appellee,

v.

CHARLES BROWN, JR.,

Defendant - Appellant.

Appeals from the United States District Court for the Eastern
District of Virginia, at Alexandria. Claude M. Hilton, Senior
District Judge. (1:11-cr-00592-CMH-1; 1:11-cr-00592-CMH-2)

Argued: October 31, 2013 Decided: February 20, 2014

Before NIEMEYER and WYNN, Circuit Judges, and Louise W.
FLANAGAN, United States District Judge for the Eastern District
of North Carolina, sitting by designation.
Affirmed by unpublished opinion. Judge Flanagan wrote the
opinion, in which Judge Niemeyer and Judge Wynn joined.

ARGUED: John O. Iweanoge, II, THE IWEANOGES' LAW FIRM, P.C.,
Washington, D.C.; Emma Mittelstaedt Burnham, BAKER BOTTS,
L.L.P., Washington, D.C., for Appellants. Michael Phillip
Ben'Ary, OFFICE OF THE UNITED STATES ATTORNEY, Alexandria,
Virginia, for Appellee. ON BRIEF: William H. Jeffress, Jr.,
Nicholas C. Margida, BAKER BOTTS L.L.P., Washington, D.C., for
Appellant Charles Brown, Jr. Neil H. MacBride, United States
Attorney, Marc J. Birnbaum, Special Assistant United States
Attorney, OFFICE OF THE UNITED STATES ATTORNEY, Alexandria,
Virginia, for Appellee.

Unpublished opinions are not binding precedent in this circuit.

2
FLANAGAN, District Judge:

Following a four-day trial, a jury convicted appellants

Paul Photiadis Boccone and Charles Brown, Jr., of multiple

charges related to illegal distribution of prescription drugs.

Boccone was convicted of additional health care fraud and tax

charges. The convictions arose from Boccone’s operation of

Chantilly Specialists, a pain management clinic in Chantilly,

Virginia, and Brown’s participation as a licensed nurse

practitioner in the clinic’s operations. On appeal, Boccone and

Brown challenge their convictions and sentences on several

grounds, including admissibility of expert testimony,

sufficiency of the evidence, and procedural reasonableness of

the sentences. For the reasons presented below, we affirm.

I.

In an indictment filed December 22, 2011, the government

charged Boccone and Brown with conspiracy to distribute

controlled substances, under 21 U.S.C. § 846 (Count 1), and

distribution of controlled substances, in violation of 21 U.S.C.

§ 841(a)(1) and 18 U.S.C. § 2 (Boccone, Counts 2-9; Brown,

Counts 2, 7, 9). Boccone also was charged with possession of a

firearm in relation to drug trafficking, under 18 U.S.C. §

924(c) (Count 10), health care fraud, under 18 U.S.C. § 1347

(Counts 11-16), and failure to pay employment taxes, under 26

U.S.C. § 7202 (Counts 17-28).

3
 At trial, the government presented testimony by former

employees and patients of Chantilly Specialists, relatives of

patients, as well as an expert witness in the field of pain

management. Appellants introduced testimony by Boccone, Brown,

and an expert with respect to the cause of death of several

patients. The evidence, viewed in the light most favorable to

the government, may be summarized as follows.

Boccone was the owner and president of Chantilly

Specialists from late 2005 to around December, 2011. He has a

Juris Doctor degree, but no medical training. He employed

several medical providers at Chantilly Specialists, including

Brown, who was a nurse practitioner licensed to prescribe

medication under Virginia law under the supervision of a

physician. When Brown began work at Chantilly Specialists in

July 2009, Dr. Carol Currier was a physician employed at the

clinic, designated as supervising physician for Brown. Dr. Joel

Match took over in this position from Dr. Currier in 2011.

During the time that Dr. Currier was designated as supervising

physician, and for some of the time that Dr. Match was

designated as supervising physician, Boccone also provided

direction to Brown in his treatment of patients and prescribing

of medication.

Boccone and Brown interacted nearly every day at the

office. Boccone often was in the examination room with patients

4
during medical appointments. Boccone interfered sometimes in

medical treatment decisions, including by giving medical

suggestions and opinions regarding medications and dosage. In

some instances, Brown signed prescriptions that Boccone filled

out with medication amounts specified. Boccone also wore a lab

coat and sometimes referred to himself as “Dr. Boccone.”

In contrast to Boccone and Brown, Dr. Currier generally was

present at Chantilly Specialists only once or twice a week. She

was not told of positive drug screens, and she was not told of

patient deaths, except once, although she had asked to be kept

informed of such information.

After Dr. Match started employment at Chantilly

Specialists, Boccone sometimes steered patients from Dr. Match

to Brown, the result being that they would continue to get

medications they were on before, whereas Dr. Match would have

reduced medication pending clinical tests. After August 2011,

Dr. Match realized that Brown did not always follow his

instructions and ultimately recommended that Boccone terminate

Brown. Dr. Match, like Dr. Currier, was not aware of the full

extent of treatment practices at Chantilly Specialists.

Regarding typical practices at the clinic, patient visits

generally were limited to fifteen to twenty minutes. Boccone

directed use of an egg timer to limit visit times. Brown

generally would see about four patients per hour. Patients

5
typically did not get physical examinations. They sometimes

received medications without clinical information in their

charts or documentation of treatment at other facilities. A lead

medical assistant employed at the clinic between January 2011

and March 2012 observed that he “found unusual the massive

amounts of medications people were getting.” (JA 128).

The waiting room was extremely crowded, and some patients

had track marks and exhibited other indicia that they were

suffering from addiction or were in recovery. Many patients at

the clinic traveled long distances for their prescriptions,

including six or seven hours away from locations in Kentucky,

West Virginia, and Tennessee. Some patients became agitated or

angry if they did not get medications they sought, and police

frequently responded to reports of unruly patients at the

clinic. As a result of the conditions in the office, Boccone

carried a firearm at work.

The government presented testimony and evidence regarding

several former patients of Chantilly Specialists who received

prescriptions following office visits with Brown. Justin

McConnell was a patient between about 2008 and October 2011. At

his first visit, McConnell did not provide medical records from

prior providers. He received a prescription including 15

6
milligrams of oxycodone, 1 which was an increase over the amount

he claimed he was receiving from a podiatrist at the time.

McConnell never received a physical examination while a patient

at Chantilly Specialists, and he never saw Dr. Currier. As his

tolerance grew for pain medications, McConnell received an

increase in prescriptions to the point that he was addicted to

the medication, and he was receiving prescriptions for 80

milligram OxyContin and 30 milligram oxycodone pills, in

addition to other medications. At times, Brown called McConnell

on his personal cell phone, and McConnell was nervous about

prescriptions being changed depending on whether he called Brown

back. Brown made McConnell uncomfortable by giving him “bear

hug[s]” and sitting on his lap in the office. (JA 192).

Eric Honesty was a patient from about August 2008 until

February 2011. Honesty’s typical appointments took ten to

fifteen minutes, and he never received any physical examination

at Chantilly Specialists. Boccone and Brown were involved

jointly with some of Honesty’s medical visits at Chantilly

Specialists, and they increased his prescriptions over time up

1
“Oxycodone is a potent and addictive opioid that is
classified as a Schedule II drug under the Controlled Substances
Act.” United States v. McIver, 470 F.3d 550, 553 n.3 (4th Cir.
2006) (citing 21 U.S.C. § 812 (2000); 21 C.F.R. § 1308.12(b)(1)
(2004)). “It is marketed in instant-release form under trade
names such as Roxicodone, Roxicet, OxyIR, and OxyFAST, and in a
controlled release form as OxyContin.” Id.

7
to 680 to 700 narcotic pain pills per month. At one visit,

Honesty agreed to return 80 milligram OxyContin pills to Boccone

and Brown in exchange for a prescription increase. Honesty

returned “thousands” of 80 milligram pills in this manner. (JA

337). Three times when he attempted to take the medications as

written in his prescriptions, he overdosed. At one point,

Boccone and Brown instructed Honesty to take only half of the

pills they had prescribed for him. During the time that Honesty

was a patient at Chantilly Specialists, Honesty was charged with

unlawful distribution of oxycodone, some of which he obtained by

filling prescriptions issued by Brown.

King Dao was a patient from approximately 2009 to 2011. He

received pain medications, including 80 milligram OxyContin and

30 milligram oxycodone pills, following appointments with Brown

and at times at direction of Boccone. He received medications

despite having been tested positive for cocaine, and at one

point he received medications after having spent 78 days in jail

following an arrest for prescription fraud at Chantilly

Specialists, with no medical examination.

Michael Rogers was a patient from 2007 to the date of his

death, on April 8, 2010. He drove about six hours from Johnson

City, Tennessee to receive prescriptions at the clinic. Boccone

directed an increase in his pain medications in February 2009,

to 80 milligram OxyContin and 30 milligram Roxicodone pills, a

8
level that was maintained by providers, including Brown, until

Rogers’s death. Brown admitted making changes to Rogers’s

medical chart after learning of Rogers’s death.

The government also introduced testimony and a report of an

expert witness qualified in the field of pain management, Dr.

Robin Hamill-Ruth. Testifying as to standards of practice in the

field of pain management, she summarized guidelines for

prescribing medications for chronic pain, as well as standards

for evaluations, referrals, documentation, periodic review and

examinations. Dr. Hamill-Ruth also identified “red flags”

indicating patients with problems with addiction, abuse, or

diversion of medication, which would signal to a provider that

there is not legitimate medical purpose for prescriptions.

These include traveling long distances to receive medications,

early refills, frequent calls, lost prescriptions, violent

behavior, and receiving treatment from multiple providers. She

also described the significance of 80 milligram OxyContin pills,

which is a high dosage amount that she had never prescribed in

her twenty-five years of pain management practice.

In addition, Dr. Hamill-Ruth outlined her review of certain

patient records, including those for Honesty, Dao, and Rogers,

underlying individual distribution charges in this case. For

each patient reviewed, Dr. Hamill-Ruth concluded that the entire

course of treatment was outside the bounds of the accepted

9
standard of care for pain management practice and for no

legitimate medical purpose. She cited in each case indicia that

should have led a reasonable, licensed medical practitioner to

cease or reduce making prescriptions, require diagnostic

examinations, and monitor patients to ensure legitimate medical

care.

Finally, the government introduced testimony regarding

Boccone’s health care billing fraud and failure to pay taxes.

With respect to billing fraud, the provider listed in the

medical record for one medical visit was Boccone, whereas the

provider billed to Medicare was a physician’s assistant. With

respect to the tax charges, Boccone failed to pay employment

taxes despite withholding tax from employee paychecks.

Upon the close of the government’s evidence, the government

voluntarily moved to dismiss three of the health care fraud

charges (Counts 11, 12, and 13), which motion the district court

granted. Defendants moved for judgment of acquittal at that

time, and again moved for judgment of acquittal following the

close of their case, which the district court denied.

Following closing argument and jury instructions, the jury

found Boccone guilty of the conspiracy charge (Count 1), six of

the distribution charges (Counts 2, 3, 4, 5, 7, and 9), one

health care fraud charge (Count 14), and all of the tax charges

(Counts 17-28). The jury found Boccone not guilty of two of the

10
distribution charges (Counts 6 and 8), and possession of a

firearm in furtherance of a drug trafficking crime (Count 10).

The jury found Brown guilty of the conspiracy charge (Count 1)

and all three of the distribution charges against him (Counts 2,

7, 9). Finally, the jury found that death did not result from

the use of the substance distributed in Count 9, for patient

Rogers.

In preparation for sentencing, the probation office

prepared a presentence report, which calculated a guideline

range of 360 months to life imprisonment for Boccone and a

guideline range of 188 to 235 months imprisonment for Brown.

After adopting the guideline ranges in the presentence reports

without change, the court varied downward, sentencing Boccone to

180 months imprisonment and Brown to 60 months imprisonment.

These appeals followed.

II.

A.

We address first Boccone’s argument that the district court

erred in allowing admission of the expert report and testimony

of Dr. Hamill-Ruth.

“We review for abuse of discretion the district court’s

decision to admit expert testimony under Federal Rule of

Evidence 702.” United States v. Wilson, 484 F.3d 267, 273 (4th

Cir. 2007) (citing Kumho Tire Co. v. Carmichael, 526 U.S. 137,

11
152 (1999)). “We will not vacate a conviction unless we find

that the district court judge acted arbitrarily or irrationally

in admitting evidence.” United States v. Basham, 561 F.3d 302,

326 (4th Cir. 2009) (internal quotations omitted). In addition,

evidentiary rulings are subject to harmless error review.

United States v. Mouzone, 687 F.3d 207, 216 (4th Cir. 2012).

Federal Rule of Evidence 702 provides:

A witness who is qualified as an expert by knowledge,
skill, experience, training, or education may testify
in the form of an opinion or otherwise if: (a) the
expert's scientific, technical, or other specialized
knowledge will help the trier of fact to understand
the evidence or to determine a fact in issue; (b) the
testimony is based on sufficient facts or data; (c)
the testimony is the product of reliable principles
and methods; and (d) the expert has reliably applied
the principles and methods to the facts of the case.

Fed. R. Evid. 702. “A ‘trial judge must have considerable

leeway in deciding in a particular case how to go about

determining whether particular expert testimony is reliable.”

Wilson, 484 F.3d at 273 (quoting Kumho Tire, 526 U.S. at 152).

“Thus, ‘Rule 702 grants the district judge the discretionary

authority, reviewable for its abuse, to determine reliability in

light of the particular facts and circumstances of the

particular case.’” Id. (quoting Kumho Tire, 526 U.S. at 158).

The government contends as an initial matter that we need

not reach Boccone’s arguments as to admissibility of Dr. Hamill-

Ruth’s testimony because it was irrelevant with respect to

12
Boccone’s distribution of controlled substances. The government

points out correctly that to convict Boccone of distribution of

controlled substances, it need only show that Boccone, not a

licensed medical provider, distributed or caused the

distribution of a controlled substance. See 21 U.S.C. §

841(a)(1); 18 U.S.C. § 2.

Nevertheless, Boccone is charged in this case not only with

distributing controlled substances individually, but also in

concert with and in conspiracy with other medical providers,

particularly Brown. In order to convict a licensed medical

provider of unlawful distribution of controlled substances, the

government must prove that the provider’s “‘actions were not for

legitimate medical purposes in the usual course of his

professional medical practice or [were] beyond the bounds of

medical practice.’” United States v. Singh, 54 F.3d 1182, 1187

(4th Cir. 1995) (quoting United States v. Tran Trong Cuong, 18

F.3d 1132, 1141 (4th Cir.1994)). As discussed below in

addressing the sufficiency of the evidence, Boccone’s

convictions may rest at least in part on the theory that Boccone

directed Brown to issue prescriptions that were not for

legitimate medical purposes or were beyond the bounds of medical

practices.

Accordingly, expert testimony regarding whether treatment

in this case was beyond the bounds of medical practice is

13
relevant to the counts of conviction against both Brown and

Boccone. We turn, therefore, to address Boccone’s arguments as

to the admissibility of that testimony.

Boccone contends that Dr. Hamill-Ruth’s testimony and

report does not meet the standards set forth in Fed. R. Evid.

702 for multiple reasons, including that Dr. Hamill-Ruth (1) did

not accurately set forth the standards of model policies and

guidance on prescribing narcotics, (2) used only sixteen hours

to review thousands of pages of medical records, (3) did not

examine any of the patients referred in her report, (4) did not

adequately specify records reviewed, and (5) stated legal

conclusions such as “it is illegal” within her written report.

This court previously has upheld the use of expert medical

testimony similar in many respects to the testimony of Dr.

Hamill-Ruth. For example, in United States v. McIver, 470 F.3d

550 (4th Cir. 2006), the government offered testimony of an

anesthesiologist qualified as an expert in pain management, who

concluded, “[b]ased on his review of certain patient records,”

that the “treatment of several of Appellant’s patients fell

outside the parameters of legitimate medical practice.” Id. at

556. For one patient, he opined that “there was ‘no legitimate

reason to be prescribing’ combinations of opioids in such high

doses based on the patient’s medical conditions,” and in light

of the patient’s “history of drug abuse.” Id. For another, he

14
testified that it was “outside the legitimate practice of

medicine for Appellant to prescribe high doses of opioids given

[the patient’s] history of negative drug screens.” Id.

Similarly, in United States v. Allere, 430 F.3d 681 (4th

Cir. 2005), a physician qualified as an expert reviewed selected

medical files in evaluating whether prescriptions were issued

outside the scope of legitimate medical practice. Id. at 686.

The expert testified that “many of the prescriptions lacked

appropriate documentation or had no ‘follow up’ treatment, that

the defendants ignored ‘red flags’ indicative of drug abuse, and

that certain prescriptions and dosages were inappropriate.” Id.

Likewise, in Tran Trong Cuong, an expert provided testimony

following a medical file review, opining, for example, “that

persons claiming . . . severe pain over a long period of time

should have had additional reports in their files of x-ray

examinations, blood tests and other procedures attempting to

identify the source of the pain.” Id.; see also United States v.

Hurwitz, 459 F.3d 463, 467 (4th Cir. 2006) (“The government’s

expert witnesses testified that a doctor who knowingly

prescribed opioids to an addict or to a patient the doctor knew

was selling the drugs on the street was acting outside the

bounds of legitimate medical practice”); Singh, 54 F.3d at 1187

& n.3 (expert testified as to “the inappropriateness of the

15
prescriptions,” upon review of “information relating to” each

patient).

In this case, Dr. Hamill-Ruth was qualified, without

objection, as an expert in pain management. Similar to the

expert testimony in McIver, Allere, and Tran Trong Cuong, Dr.

Hamill-Ruth described her understanding of the standard of care

for treating patients in a pain management context and then

compared the treatment shown in the medical records in the case

with that standard of care, finding the treatment shown to be

outside legitimate medical practice. In doing so, she cited red

flags similar to those identified by experts in the cases noted

above, including negative drug screens, lack of documentation

and follow up treatment for medical conditions, prescriptions

over a long period of time without medical examinations, high

dosage combinations, and prescriptions despite signs of drug

addiction or street sales. (JA 3827-3836; 536-551).

In light of Dr. Hamill-Ruth’s qualifications and detailed

manner in which she outlined her review of patient records and

evidence considered as a basis for her opinions, we conclude

that her testimony and report were both scientifically valid and

helpful to the jury. Contrary to Boccone’s argument here, there

is no requirement in our precedent that the expert must examine

the patients whose files are reviewed, or set forth a particular

model policy or standard, or cite to particular records or

16
amounts of records for any particular patient. Rather, the

points of criticism raised by Boccone go to the weight of the

testimony, and these points were open for exploration upon

cross-examination of the expert witness. 2 Indeed, as the court

noted in McIver, such cross-examination enabled the appellants

to point out “varying theories of pain management, . . .

differences in points of view as to appropriate levels of pain

medication,” and make challenges to the expert’s “opinions

regarding [the appellant’s] treatment of specific patients.”

McIver, 470 F.3d at 556.

We address separately Boccone’s argument that the report

improperly states a legal conclusion, referencing in particular

the statement by Dr. Hamill-Ruth that “[i]t is illegal and

grossly substandard for a person without medical license and DEA

registration to make therapeutic decisions and alter prescribing

of controlled substances.” (JA 3828). This statement is made in

the context of Dr. Hamill-Ruth’s review of Rogers’s medical

file, in which Boccone directs medication dosage and treatment

for Rogers in an office visit note. (Id.).

2
Boccone also urges the court to consider a report prepared
by Jason Brajer, MD, approximately two months following the jury
verdicts in this case. Dr. Brajer comments upon and provides a
counter-point to conclusions reached by Dr. Hamill-Ruth in her
expert report. In the same vein as the criticisms noted above,
the points raised by Dr. Brajer more properly go to the weight
of the testimony rather than its admissibility.

17
 This court has observed that “opinion testimony that states

a legal standard or draws a legal conclusion by applying law to

the facts is generally inadmissible.” McIver, 470 F.3d at 562.

Nevertheless, an expert may testify that treatment was “outside

the bounds of . . . professional medical practice,” or that

“treatment of certain patients was either illegitimate or

inappropriate.” Id. Such language “falls within the limited

vernacular that is available to express whether a doctor acted

outside the bounds of his professional practice.” Id.

In accord with McIver, the expert’s statement here that “it

is illegal and grossly substandard” for a person without medical

license to make therapeutic decisions, in reference to Boccone’s

involvement in treatment of Rogers, reasonably articulates the

extent of departure from usual professional practice in this

case. The statement thus is relevant to the jury’s

determination that treatment of Rogers was “outside the bounds

of . . . professional medical practice.” Id. In any event,

even assuming that the reference to “it is illegal” crossed

outside of the “limited vernacular,” id., available in this

context to describe legitimate medical practice, we conclude

that the error was harmless, given the weight of evidence

against Boccone apart from that reference in Dr. Hamill-Ruth’s

report. See United States v. McLean, 715 F.3d 129, 143 (4th

Cir. 2013) (“[W]e need only say with fair assurance, after

18
pondering all that happened without stripping the erroneous

action from the whole, that the judgment was not substantially

swayed by the error.”) (internal quotations omitted).

In sum, the district court properly admitted Dr. Hamill-

Ruth’s testimony and report, and Boccone cannot establish error

warranting reversal of his convictions on the basis of such

testimony and report.

B.

Appellants argue that the evidence was insufficient to

convict them of any of the counts of conviction.

We must sustain the jury’s verdict “if there is substantial

evidence, taking the view most favorable to the Government, to

support [the convictions].” United States v. Moye, 454 F.3d

390, 394 (4th Cir. 2006) (en banc) (internal quotations

omitted). “[S]ubstantial evidence is evidence that a reasonable

finder of fact could accept as adequate and sufficient to

support a conclusion of a defendant’s guilt beyond a reasonable

doubt.” United States v. Burgos, 94 F.3d 849, 862 (4th Cir.

1996) (en banc). In reviewing a sufficiency argument, we “must

consider circumstantial as well as direct evidence, and allow

the government the benefit of all reasonable inferences from the

facts proven to those sought to be established.” United States

v. Tresvant, 677 F.2d 1018, 1021 (4th Cir. 1982). In addition,

we “may not weigh the evidence or review the credibility of the

19
witnesses,” as “those functions are reserved for the jury.”

United States v. Wilson, 118 F.3d 228, 234 (4th Cir. 1997).

1.

We address first the sufficiency of the evidence to convict

appellants of the individual counts of distribution of

controlled substances under 21 U.S.C. § 841.

Section 841 provides that “[e]xcept as authorized by this

subchapter, it shall be unlawful for any person knowingly or

intentionally . . . to manufacture, distribute, or dispense . .

. a controlled substance.” 21 U.S.C. § 841(a)(1). An exception

pertinent to this case is set forth in § 822(b), which provides:

Persons registered by the Attorney General under this
subchapter to manufacture, distribute, or dispense
controlled substances or list I chemicals are
authorized to possess, manufacture, distribute, or
dispense such substances or chemicals (including any
such activity in the conduct of research) to the
extent authorized by their registration and in
conformity with the other provisions of this
subchapter.

Id. § 822(b). As the court previously has observed, regulations

promulgated by the Attorney General provide “that a prescription

for a controlled substance is effective only if it is ‘issued

for a legitimate medical purpose by an individual practitioner

acting in the usual course of his professional practice.’”

Hurwitz, 459 F.3d at 475 (citing 21 C.F.R. § 1306.04(a)).

Thus, to convict a medical practitioner under § 841(a)(1),

the government must prove that (1) the defendant “distributed or

20
dispensed a controlled substance,” (2) he “acted knowingly and

intentionally,” and (3) his “actions were not for legitimate

medical purposes in the usual course of his professional medical

practice or were beyond the bounds of medical practice.” Singh,

54 F.3d at 1187 (quoting Tran Trong Cuong, 18 F.3d at 1141).

“[T]here are no specific guidelines concerning what is required

to support a conclusion that an accused acted outside the usual

course of professional practice.” Id. (quoting United States v.

August, 984 F.2d 705, 713 (6th Cir. 1992)). “Rather, the courts

must engage in a case-by-case analysis of evidence to determine

whether a reasonable inference of guilt may be drawn from

specific facts.” Id. (quoting August, 984 F.2d at 713).

A defendant’s “good faith” generally is relevant to a

jury’s determination of whether a defendant acted outside the

bounds of accepted medical practice or without a legitimate

medical purpose. Hurwitz, 459 F.3d at 476 & 480. Accordingly a

defendant cannot be convicted “if he merely made an honest

effort to prescribe in compliance with an accepted standard of

medical practice.” Id. at 476-77 (quoting United States v.

Moore, 423 U.S. 122, 142 (1975)). Good faith in this context is

an objective rather than subjective standard, meaning that “good

faith is not merely a doctor’s sincere intention towards the

people who come to see him, but, rather, it involves his

sincerity in attempting to conduct himself in accordance with a

21
standard of medical practice generally recognized and accepted

in the country.” Id. at 478 (quoting United States v. Hayes, 794

F.2d 1348, 1351 (9th Cir. 1986)).

Brown contends that he should be subjected to a different

standard because, as a nurse practitioner in Virginia, he was

authorized to prescribe only under supervision of a licensed

physician. Brown fails to articulate, however, the manner in

which the elements of the distribution offense should be

different for a nurse practitioner as opposed to a physician.

Indeed, the district court’s jury instructions set forth the

government’s burden of proof in terms which apply equally to

physicians and others “licensed and authorized to prescribe

controlled substances.” (JA 818). In accordance with the

standards set forth above, the district court instructed the

jury that the government must prove beyond a reasonable doubt

“that the defendant or defendants’ action were not for the

legitimate medical purposes in the usual course of professional

practice or were beyond the bounds of medical practice.” (JA

817). Under these instructions, Brown, as a nurse practitioner,

is held to the same standard of practice as any other licensed

medical practitioner, namely the requirement to make an “honest

effort to treat his patients in compliance with the accepted

standards of medicine.” (JA 818) (emphasis added). Brown did

22
not object to these instructions. Nor does he contend on appeal

that the jury instructions were improper.

Brown contends, nonetheless, that the government was

required to introduce evidence that his conduct fell below a

standard of practice for a nurse practitioner, as opposed to the

standard of practice for a physician, and that the government

did not do so in this case. We are not persuaded by Brown’s

premise that the standard of medical practice should be any

different for a nurse practitioner licensed to prescribe

medication and a physician licensed to prescribe medication. In

both instances the prescription – whether by a physician or a

nurse practitioner – must be within the scope of usual medical

practice and for a legitimate purpose. A nurse practitioner,

like any other medical practitioner, “is not free deliberately

to disregard prevailing standards of treatment.” Hurwitz, 459

F.3d at 479 (quoting United States v. Vamos, 797 F.2d 1146, 1151

(2d Cir. 1986)); see also United States v. Lawson, 682 F.2d 480

(4th Cir. 1982) (in affirming § 841(a)(1) convictions of

pharmacist, stating that one element is “whether [the defendant]

knew that the purported prescription was not issued for a

legitimate medical purpose or in the usual course of medical

practice”).

Brown also suggests that if a supervising physician

authorizes a nurse practitioner to write prescriptions and does

23
not revoke his ability to prescribe, then there is no basis to

convict him absent further evidence that he “endeavored to

conceal his prescriptions” or that the nurse and the physician

“are deliberately working in concert to issue unlawful

prescriptions.” (Brown Br. at 34). According to Brown, in the

absence of such evidence of concealment or collusion, a nurse

practitioner should be insulated from culpability because a

physician has agreed to allow the nurse practitioner to

prescribe medication. Such a bright-line rule, however, runs

counter to this court’s prior recognition that “there are no

specific guidelines concerning what is required to support a

conclusion that an accused acted outside the usual course of

professional practice,” and the court “must engage in a case-by-

case analysis of evidence to determine whether a reasonable

inference of guilt may be drawn from specific facts.” Singh, 54

F.3d at 1187 (quotations omitted).

Contrary to Brown’s suggestion, although evidence of

concealment or collusion with a physician may be sufficient to

convict a nurse practitioner of unlawful distribution of

controlled substances, such evidence is not necessary to secure

a conviction. A reasonable jury may conclude based upon other

facts and circumstances that a nurse practitioner issued

prescriptions knowing that they were not for a legitimate

purpose or were outside the usual course of professional

24
practice. In this case, for instance, Brown was not merely

acting in isolation, solely under direction of a licensed

physician. Rather, as we will detail below, this case involved

more complex relationships between a non-physician office

manager who took an active role in treatment decisions

(Boccone), other medical and non-medical employees (including

Brown), and supervising physicians who did not maintain a

constant presence in the practice (including Drs. Currier and

Match).

With these considerations in mind, we now turn to the

sufficiency of the evidence supporting the individual counts of

distribution of controlled substances, beginning with Brown’s

convictions.

a.

Brown was convicted of three counts of unlawful

distribution of a controlled substance, oxycodone, corresponding

to prescriptions he wrote for three patients: King Dao, on

October 23, 2009 (Count Two); Eric Honesty, on June 7, 2010

(Count Seven); and Michael Rogers on April 5, 2010 (Count Nine).

Brown concedes that the government proved the first two elements

of each of these offenses — that Brown distributed oxycodone,

and that he did so knowingly and intentionally to each of these

patients. He contends, however, that the government failed to

prove the third element — that the prescriptions were

25
illegitimate or outside the course of professional practice. We

disagree.

The government introduced several categories of evidence

supporting the third element of conviction on each of these

charges. First, as to each charged distribution, the government

introduced evidence that Boccone directed the treatment

prescribed. In particular, with respect to Dao, on October 23,

2009, Boccone entered a treatment note stating:

New regiment [sic] as follows: Opiate Tollerant [sic].
Discontinue all medications. 60mg Oxsycontin [sic]
for long acting releif [sic] from chronic intractable
pain to be taken with 40mg Oxycontin to establish
baseline releif [sic]. 40mg to be taken 3 hours after
taking a 60mg. 1 10mg methadone to be taken at
bedtime to affect the CYP1A4 Enzyme decreasing
metabolising of oxycontin to increase duration. 2ml
liquid Oxicodone for immediate releif [sic] in AM when
awakening.

(JA 2731). Earlier in the same day, Boccone entered further

notes regarding Dao’s pain symptoms. (JA 3030). At the same

time, Brown is listed as medical provider in the medical

records, and Brown issued a prescription for 40 milligram and 60

milligram OxyContin pills that same day. (JA 3030-3033; 2671-

2675).

With respect to Honesty, on June 7, 2010, Boccone entered a

treatment note stating that he restored an OxyContin

prescription:

Restored Oxycontin to 3 tablets every 4 hours while
awake from 10:00AM until 10:00PM with one additional

26
 at last dosage to total 13 tabs per day; Resored [sic]
Roxicodone to 3 tabs q6 with one additional HS, Zanax
at 1mg q12, cymbalta 60mg 1 tab q 12, changed
neurontin to 600 q6.

(JA 2136). That same day, Brown issued four prescriptions for

Honesty, including two separate 80 milligram oxycodone

prescriptions. (JA 1974-1981).

Finally, with respect to Rogers, in an entry in Rogers’s

medical records made by Boccone on February 12, 2009, Boccone

increased Rogers’s oxycodone regimen to the level that it

remained until Rogers’s death, on April 8, 2010. (JA 1715-

1717). He also opined in a treatment note that Rogers

“[r]equires physical therapy,” “has developed a very high

tolerance to opiates,” and has a spinal cord injury with “no

alternative treatment.” (JA 1781). On April 5, 2010, Brown

issued prescriptions in the amount set by Boccone on February

12, 2009. (JA 1700-1702, 1715).

In light of the above, we reject Brown’s contention that

the record contains no evidence showing that Boccone directed

Brown to write any of the three charged prescriptions. While

Brown cites lack of testimony by the patients themselves as to

who directed the prescriptions, the documentary evidence,

combined with testimony regarding the working relationship

between Boccone and Brown, amply supports the inference that

Boccone directed the prescriptions.

27
 Moreover, we reject Brown’s contention that, even if

Boccone directed the prescriptions, the government failed to

present any evidence that such conduct rendered the

prescriptions illegitimate. The statute itself provides that it

is illegal for a non-licensed individual to distribute

controlled substances — or to direct or cause distribution

thereof. See 21 U.S.C. § 841(a)(1); 18 U.S.C. § 2. In addition,

Dr. Hamill-Ruth opined that it is “[a]bsolutely not appropriate”

for a non-licensed person to direct, oversee, or guide

prescriptions for narcotic pain medications. (JA 530; see JA

3828). Thus, the jury properly could infer that if Boccone

directed or caused the prescriptions to be issued, this itself

established, or was one factor supporting, the conclusion that

the prescriptions were illegitimate. See United States v. Orta-

Rosario, 469 Fed. Appx. 140, 144 (4th Cir. 2012) (in affirming

convictions of doctor and employee of online prescription

service, noting factors relevant to guilt, including “permitting

non-medical personnel to write prescriptions with pre-signed

bland prescription forms”); United States v. Mahar, 801 F.2d

1477, 1487 (6th Cir. 1986) (“[T]hat patients were regularly sold

controlled substances . . . selected by non-physician lay

employees of the Clinic would further support a finding that

controlled substances were issued outside the usual course of

medical practice and for no legitimate medical purpose.”).

28
 Apart from evidence of Boccone’s involvement in the

individual prescriptions underlying the distribution charges,

the government also introduced evidence that Boccone influenced

the entire course of treatment of each patient, both in the way

he managed his office and in his interactions with individual

patients. For example, Dao testified that at one point he was

arrested at Chantilly Specialists for prescription fraud, and he

was unable to take his prescription with him at the time of

arrest. After spending 78 days in jail, he returned to

Chantilly Specialists to pick up his prescription, and he was

provided his prescription without seeing any medical

practitioner, in the presence of Boccone, Boccone’s wife, and

another individual. (JA 391). Honesty agreed with Brown and

Boccone to return 80 mg OxyContin pills to Boccone and Brown.

(JA 336-337). 3 And, as noted above, Boccone set the level of

3
Brown contends the evidence is insufficient to link him to
the agreement with Honesty, because in some of his testimony
Honesty references Brown and Boccone together, without
identifying specific activity by Brown. He also contends this
agreement is irrelevant to the charged prescriptions. Viewing
the testimony in this manner, however, neglects to draw
inferences in favor of the government and impermissibly invites
the court to weigh the evidence. Honesty’s testimony provides a
basis upon which to infer an unlawful agreement between Honesty,
Brown, and Boccone, which is one factor among several showing
that treatment of Honesty was outside the scope of medical
practice, and that Brown knew that the specific charged
prescription, as part of that course of treatment, was
illegitimate.

29
medication for Rogers that lasted from 2009 to his death in

2010. (JA 1715-1717).

In addition to evidence of Boccone’s involvement in medical

decisions, the government introduced further evidence that the

entire course of treatment of patients Dao, Honesty, and Rogers,

was illegitimate and outside the usual course of medical

practice. This evidence took the form of indicia or red flags

of diversion, addiction, and abuse, as highlighted in the report

and testimony of Dr. Hamill-Ruth.

In particular, Dao received prescriptions for large volumes

of pain medication, continuing without change over an extended

period of time, without referrals for alternative treatment or

therapy for “underlying medical issues that are very

concerning.” (JA 549, 3833). Diagnostic tests were

insufficient “to support the diagnosis of intractable pain,” and

provided “no good indication to be prescribing this man chronic

opiates as far as their documentation is concerned.” (JA 549).

Additional red flags included multiple early refills, multiple

calls, sporadic visits, and drug screens, all as indicia that

prescriptions are fueling a drug addiction. (JA 550-551). A

pharmacy called in 2010 to report early refill requests, an

incident in which Dao was with another person who attempted to

pay with counterfeit money, and Dao’s provision of medication to

another person. (JA 2710, 3833). On March 23, 2011, Dao

30
pleaded guilty to prescription fraud based on prescriptions

received from Chantilly Specialists. (JA 2659). Dao met with

Brown for two appointments after returning from jail following

his arrest for prescription fraud. (JA 389, 391, 2700-2705). As

noted above, Dao picked up prescriptions that had been filled on

the day of his arrest, without any medical examination. (JA 390-

391). Dao received prescriptions despite having drug screens on

several occasions that were positive for use of cocaine and/or

negative for proscribed medications (JA 386, 3205, 3834).

Honesty testified that he never received any physical

examination while being seen at Chantilly Specialists. (JA

330). According to Dr. Hamill-Ruth, “there was no good

indication in the record for prescribing him significant

medication doses,” and “no outside documentation at the initial

visit.” (JA 547). Boccone and Brown increased Honesty’s

prescriptions over time, up to around 680 to 700 narcotic pain

pills per month. (JA 335, 338). Three times when he attempted

to take the medications as written in his prescriptions, he

overdosed, and he informed Boccone and Brown of the overdoses.

(JA 338-339). Further red flags included loss of medications;

lack of documentation of injuries and outside medical visits;

lack of documentation of prescriptions from other providers;

escalating aberrant behavior including threats prompting

referrals to psychiatry for “substance abuse, bipolar”

31
disorders; lack of evidence of compliance with referrals; and

drug tests negative for prescribed medications. (JA 1990-1991,

2152, 3834-3836). In sum, Dr. Hamill-Ruth opined “his behavior

really was very significant for abuse, and it was unconscionable

to continue to support his addiction problem without sending him

for appropriate referral.” (JA 548).

Indicia of addiction and abuse as to Rogers included that

he drove a long distance from Tennessee to receive

prescriptions, he was treated with pain medication over an

extended period from 2007 to his death in 2010, and additions

and adjustments were made without any rationale noted. (JA

3827). Additional red flags include frequent phone calls,

requests for early refills, self-escalation of dosing,

inconsistencies in reporting thefts, issues with receipt of

medication, and needing prescriptions overnighted to his home in

Tennessee, positive drug screens and an absence of documentation

as to pharmacies used. (JA 3828-3829). Further, Dr. Hamill-

Ruth opined that it was inappropriate and “flagrantly dangerous”

to prescribe Rogers the combinations of medications he received

without adequate documentation. (JA 537). As for the

prescriptions issued by Brown days before Rogers’s death, Dr.

Hamill-Ruth noted that prescriptions issued for “excessive doses

of multiple medications” raise “significant concerns” in light

of Rogers’s affliction with pneumonia. (JA 540-541).

32
 Considering all of the above, including the evidence of

Boccone’s involvement, in conjunction with indicia of diversion,

addiction, and abuse, in the medical record of these patients,

the evidence was sufficient for the jury to conclude that Brown

knew or had reason to know that prescriptions he issued were for

an illegitimate purpose or were not within the scope of usual

medical practice.

Brown raises several additional challenges as to the

evidence supporting the distribution counts of conviction, which

we find unavailing. First, following on his earlier argument

regarding the legal standard, Brown suggests that expert

testimony by Dr. Hamill-Ruth was not sufficient to convict him

because it addressed only a physician’s standard of practice and

did not address whether his own treatment fell below the

standard of a nurse practitioner. As discussed above, we

disagree that the standard of practice for a nurse practitioner

differs from that of a physician. Moreover, as to sufficiency

of her report and testimony, Dr. Hamill-Ruth did not limit her

opinion to the standard of practice for physicians, to the

exclusion of other licensed practitioners such as nurse

practitioners. Indeed, she testified as to “the practice . . .

in the field of pain management,” and guidelines that “medical

providers who practice in the field of pain management can rely

on[.]” (JA 526) (emphasis added). She specifically noted that

33
nurse practitioners, as well as physicians, are authorized to

prescribe controlled substances in Virginia. (JA 530).

Accordingly, we reject Brown’s contention that Dr. Hamill-Ruth’s

testimony was insufficient to prove that Brown’s conduct fell

below the standard of medical practice.

Brown next contends that his treatment of patients

underlying the charged offenses, including Dao, was in good

faith because these patients had legitimate medical problems.

The existence of legitimate medical problems, however, does not

compel a finding that a practitioner prescribed medications in

good faith. Indeed, in Singh, the court upheld convictions of a

physician for unlawful distribution of controlled substances,

even though patients to which medications were prescribed had

numerous physical ailments. For example, one patient was

diagnosed with “lumbar disc problems and seizures.” Singh, 54

F.3d at 1188. Based on the opinion of an expert witness, the

court noted that continued prescriptions of addictive drugs to

this patient, in light of indicia of alcohol abuse and

recommendations from a psychological evaluation, was “outside

the scope of a legitimate medical practice.” Id.

In this case, as in Singh, patients presented with medical

problems, including that Rogers had history of a gunshot wound,

(JA 3827), Dao suffered from “aching low back pain, intermittent

left L5 radiculitis and tension related neck pain,” (JA 3833),

34
and Honesty had hypertension, sleep apnea, asthma, and carpel

tunnel syndrome. (JA 3834). Nevertheless, the presence of such

legitimate medical problems in many respects supported, rather

than undermined, a determination that prescriptions were issued

outside the scope of medical practice.

To this end, Dr. Hamill-Ruth identified a disconnect

between the problems presented and the course of treatment. For

Rogers, she noted a lack of documentation regarding the nature

of injuries, and she noted “significant concerns” with

prescribing medication to Rogers, in light of his pneumonia.

(JA 541, 3827). For Dao, despite many ailments, Dr. Hamill-Ruth

noted that he was “not put on an NSAID, sent for PT, or offered

interventional pain management, any or all of which could have

helped more effectively manage his pain.” (JA 3833).

Similarly, for Honesty, “an inadequate exam is documented, and

it does not support chronic intractable pain,” and “no exam or

other data” is in the record to support some diagnoses. (JA

3834-35). Accordingly, the manner in which legitimate medical

problems are addressed, rather than the existence of the

problems in the first place, is most probative to whether

prescriptions are issued within the usual scope of medical

practice. (See JA 527).

Finally, Brown argues that he acted in good faith because

supervising doctors and the Virginia Board of Medicine never

35
stated his treatment of any patient was improper. As discussed

above, however, the level of supervision Brown received is one

factor among many bearing on the issue of whether Brown knew

that prescriptions were issued outside the scope of legitimate

medical practice. While Brown contends that supervising

physicians and the Board never criticized his treatment of any

patient, Brown also points to no evidence that they approved

specific prescriptions underlying the charged offenses.

The practice agreement between Brown and Dr. Currier does

not set forth parameters of supervision or approval of specific

prescriptions, nor does it restrict Brown’s prescriptive

authority beyond specifying the types of drugs which Brown may

prescribe. Rather, it is a form check-box agreement, which

states simply that Brown is “authorized by this practice

agreement” to prescribe multiple categories of Schedule II

drugs. (JA 3763). A jury reasonably could infer based on this

practice agreement that Brown maintained responsibility to

discern that a given prescription was legitimate or issued in

the course of medical practice. 4

4
Because of the limited nature of the agreement in this
case, we need not address whether conceivably a practice
agreement could include such restrictions on authority of a
nurse practitioner, and a physician could exercise such
oversight over individual prescriptions, to foreclose as a
matter of law culpability of a nurse practitioner. In this
manner, we find only theoretical significance in the fact that,
(Continued)
36
 Moreover, Dr. Currier, who was supervising physician during

the time of the charged prescriptions, testified that she did

not authorize Brown to prescribe medications in the presence of

red flags such as inconsistent drug tests, lack of treatment

records, and noncompliant or aberrant behavior. (JA 308). She

also testified that she was not sufficiently present and

informed of clinical information, nor sufficiently involved in

treatment decisions, to provide adequate oversight of individual

patient treatment. (See JA 264-265, 309).

In addressing this evidence on appeal, Brown draws

inferences in favor of the defense rather than the government.

For example, Brown opines that “[g]iven [their] practice

agreement, the fact that Dr. Currier did not expressly authorize

Mr. Brown’s actions – which is all the transcript shows – was

tantamount to approval of Mr. Brown’s prescribing practices.”

(Brown Reply Br. at 6). Similarly, Brown suggests that the jury

was required to infer from Brown’s lack of training and

supervision that Brown believed in good faith that the

prescriptions he issued were legitimate. But, a contrary

as Brown notes, Virginia law authorizes a practice agreement to
“restrict such prescriptive authority as deemed appropriate by
the physician providing direction and supervision.” (Brown Br.
at 33, quoting Va. Code Ann. § 54.1-2957.01(A)). It suffices in
this case that no such restrictions were embodied in Brown’s
practice agreement.

37
inference is also reasonable. In particular, the jury reasonably

could infer that, in the absence of adequate supervision and

oversight from Dr. Currier, Brown chose to follow directions of

Boccone in making the charged prescriptions, including

prescribing a high volume of medications for as long as patients

were willing to receive them, all with knowledge of or

deliberate blindness to the fact that the prescriptions were

without grounding in legitimate medical practice.

In sum, substantial evidence supported Brown’s convictions

for distribution of controlled substances.

b.

Turning next to Boccone’s convictions for distribution of

controlled substances, we conclude that the evidence amply

supported the conclusion that Boccone knowingly distributed

oxycodone to six patients by entering directions for

prescriptions in each patient’s medical file on the dates of the

charged distribution.

In particular, as we have already noted, the jury

reasonably could infer that Boccone directed the charged

prescriptions for other patients Dao, Rogers, and Honesty. In a

similar manner, the evidence demonstrated that Boccone directed

the prescriptions for patients Diane Gisin, Linda Mumma, and

Bryan Anderson (Counts Three, Four and Five). Specifically, on

April 16, 2009, Boccone entered direction in Gisin’s medical

38
file stating “[m]aintain current regiment [sic],” and

physician’s assistant Joe Frazier signed prescriptions including

Roxicodone 30 mg and other opiate drugs. (JA 2576, 2534). In a

medical record entry on February 5, 2009, Boccone directed

maintenance of an opiate regimen and added prescriptions for

Mumma. (JA 3581-3582). Finally, in a medical record entry on

August 17, 2009, Boccone entered a detailed treatment note

including diagnosis for Anderson, and directed four days of

medication, including 80 milligram OxyContin pills. (JA 3933).

This evidence is sufficient to permit the jury to infer

that Boccone conducted the patient visits or directed

prescriptions for each patient on the date charged, thus

causing, as a non-licensed individual, distribution of

controlled substances. See 21 U.S.C. § 841(a)(1); 18 U.S.C. §

2; see also United States v. Johnson, 831 F.2d 124, 128 (6th

Cir. 1987) (“[T]he sale by a nonpractitioner of bogus

prescriptions which are in fact used to obtain controlled

substances is tantamount to the distribution of the substances

themselves and hence, is properly punishable as unlawful

distribution of drugs in violation of section 841(a)(1).”).

Further, although additional evidence was not required,

Boccone’s convictions were also supported by evidence set forth

above demonstrating that treatment of patients Dao, Rogers, and

Honesty, in concert with Brown, was outside the scope of

39
legitimate medical practice due to indicia of abuse, addiction,

and diversion. In addition, with respect to Gisin, Dr. Hamill-

Ruth opined that “[p]rescribing for this patient was

substandard,” due to inadequate documentation and evaluations

rendering prescriptions outside the bounds of usual medical

care. (JA 3838). Mumma also testified that in one instance

Boccone attempted to treat her for very high blood pressure by

bringing in during an appointment a “blister pack of medication”

and directing her to take one. (JA 453). When she refused, he

called her cardiologist and introduced himself as “Dr. Paul

Boccone.” (JA 454).

We have considered Boccone’s arguments challenging his

convictions for the distribution counts and find them

unavailing. While Boccone focuses on the lack of evidence that

he personally signed prescriptions for any of the charged

patients, such arguments do not take into account that Boccone’s

culpability rests on his conduct in directing or causing the

charged prescriptions, which, on the basis set forth above, is

supported by substantial evidence. His suggestion that medical

providers, and not Boccone, entered the directions in the

medical notes as cited above, rests upon drawing inferences from

circumstantial evidence in favor of the defense rather than the

government. Where Boccone’s name is designated in a timed

medical entry in the record, the jury reasonably may infer that

40
he conducted the medical visit, or participated in it, and then

entered the text of the entry. Further, Boccone’s contention

that other providers entered notes using his name is belied by

the fact that those same medical providers entered their own

notes in the medical record using their own names. (See, e.g.,

JA 1715-1717). Finally, Boccone’s contentions that treatment of

the patients in the charged offenses was in fact legitimate fail

for the same reasons we have rejected Brown’s challenges to the

convictions. 5

In sum, we conclude the evidence was sufficient to support

Boccone’s unlawful distribution convictions.

2.

We turn next to appellants’ convictions for conspiracy to

distribute controlled substances.

The drug conspiracy statute provides that “[a]ny person who

attempts or conspires to commit any offense defined in this

5
The court is in receipt of a letter submitted by Boccone’s
counsel post-argument, pursuant to Federal Rule of Appellate
Procedure 28(j). Under this subsection of the rule, titled
“Citation of Supplemental Authorities,” a party may submit such
a letter only “[i]f pertinent and significant authorities come
to a party’s attention after the party’s brief has been filed.”
Fed. R. App. P. 28(j). The submission here, however, does not
contain pertinent and significant authorities that came to
Boccone’s attention after his briefs were filed. Rather, it
contains citations to the record in reference to points made at
oral argument. We are thus not obligated to consider this
letter. In any event, the information provided in Boccone’s
letter does not alter the conclusions we reach above.

41
subchapter shall be subject to the same penalties as those

prescribed for the offense, the commission of which was the

object of the attempt or conspiracy.” 21 U.S.C. § 846. To

convict a defendant of conspiracy under this statute, the

government must establish three essential elements: (1) an

agreement to unlawfully distribute controlled substances existed

between two or more persons; (2) defendants knew of the

conspiracy; and (3) defendants knowingly and voluntarily became

a part of this conspiracy. See Burgos, 94 F.3d at 857.

“[I]t is not necessary to prove a formal agreement to

establish a conspiracy in violation of federal law; a tacit or

mutual understanding among or between the parties will suffice.”

McIver, 470 F.3d at 563 (quotation omitted). In addition,

“[t]he Government is not required to prove that a defendant knew

all his co-conspirators or all of the details of the

conspiracy.” United States v. Green, 599 F.3d 360, 367 (4th

Cir. 2010). In the context of unlawful distribution of

prescription drugs, conspiracy may be established where the

defendant “tacitly agreed with his patients to provide opioid

prescriptions without legitimate medical reasons for doing so.”

470 F.3d at 563. “The government can satisfy the knowledge

requirement by showing either that Appellant actually knew of

the conspiracy, or that he was willfully blind to it by

42
purposely closing his eyes to avoid knowing what was taking

place around him.” Id. (internal quotations omitted).

Much of the same evidence supporting the individual

distribution convictions also supports the conspiracy conviction

in this case. For example, the treatment of Dao, Rogers, and

Honesty, as detailed above, provides sufficient evidence of a

conspiracy to unlawfully distribute oxycodone, in light of

Boccone’s involvement in treatment decisions, in conjunction

with red flags showing that their treatment was outside the

scope of medical practice. In addition, the government’s

evidence demonstrated a conspiracy extending in scope to

treatment of other patients, such as Justin McConnell, whose

treatment at the hands of Boccone and Brown was similarly

outside the scope of medical practice. From this evidence, a

jury reasonably could conclude that appellants agreed with each

other and their patients to unlawfully distribute controlled

substances, and each knew of the conspiracy or was “purposefully

closing his eyes to avoid knowing what was taking place around

him.” McIver, 470 F.3d at 563.

Moreover, the government introduced further circumstantial

evidence that appellants entered into an agreement to distribute

prescriptions outside of medical practice. Such evidence

includes time limits placed on examinations by Boccone, scarcity

of physical exams, perfunctory visits for prescription refills

43
for large amounts of drugs, Boccone’s presence in examination

rooms during patient exams conducted by Brown and other

practitioners, close interaction between Boccone and Brown in

the office, Boccone’s processing of prescriptions and forgery of

signatures on prescriptions, Boccone’s reference to himself as

“doctor,” Brown’s conduct in signing prescriptions filled out by

Boccone or prescriptions in stacks while in exams with other

patients, and patients’ provision of gifts and services to

Boccone and Brown. (JA 128-29, 132-136, 138-39, 142-43, 165,

176, 187-88, 223-25, 257, 365, 368, 412-13).

In sum, considering together the treatment of individual

patients with evidence regarding the nature of the practice and

defendants’ role in the practice, sufficient evidence supported

the conspiracy convictions in this case.

3.

Boccone contends the evidence was insufficient to convict

him of health care fraud. The government charged Boccone with

violation of 18 U.S.C. § 1347, on the basis that he submitted a

claim to Medicare on November 3, 2009, knowing that licensed

medical provider had not performed services, particularly in

treatment of Dianne Gisin, on April 16, 2009.

The health care fraud statute provides that it is unlawful

to “knowingly and willfully execute[] . . . a scheme or artifice

(1) to defraud any health care benefit program; or (2) to obtain

44
by means of false or fraudulent pretenses, representations, or

promises, any of the money . . . [of] any health benefit

program, in connection with the delivery of or payment for

health care benefits, items, or services . . . .” 18 U.S.C. §

1347(a). The statute may be violated by a person who obtains

reimbursement from Medicare by means of false or fraudulent

statements on insurance claims. See McLean, 715 F.3d at 140.

“[T]he specific intent to defraud may be inferred from the

totality of the circumstances and need not be proven by direct

evidence.” Id. at 138.

The government introduced evidence that the person who

provided medical services for Gisin on April 16, 2009 was

Boccone, (JA 2576), whereas the provider billed to Medicare was

physician’s assistant Joe Frazier. (JA 3781-82). Considered in

conjunction with Gisin’s testimony that Boccone treated her,

this was sufficient for the jury to infer that solely Boccone

saw Gisin on that date and Frazier did not provide any medical

services. Because Boccone caused claims to be submitted to

Medicare falsely representing the provider who performed

services on the date charged, Boccone’s health care fraud

conviction is supported by substantial evidence.

Boccone argues that Medicare allows submission of a bill

for a visit with a member of a medical provider’s staff, noting

for example that Medicare billing code 99211 provides for an

45
office visit “not requir[ing] the presence of a physician,”

where “[u]sually, the presenting problem(s) are minimal.”

(Boccone Br. at 51-52). Notably, however, the billing code

submitted to Medicare in this case was 99215, not 99211. (JA

3781). In contrast to code 99211, code 99215 is reserved for

office visits requiring either a “comprehensive examination” or

“[m]edical decision making of a high complexity,” where “the

presenting problem(s) are of moderate to high severity,”

typically requiring 40 minutes spent face-to-face with the

patient. See American Medical Assoc., Current Procedural

Terminology (CPT), 10 (2009 Standard Ed.). Here the evidence

suggests the opposite – that no legitimate medical decisions

were made on April 16, 2009, much less decisions of high

complexity or following a comprehensive examination. This

further supports a determination that the bill which Boccone

submitted in this case included false and misleading information

regarding the nature of the provider and the services performed.

In sum, Boccone’s health care fraud conviction was

supported by substantial evidence.

46
 4.

Boccone argues that the evidence was insufficient to

support his convictions for failure to pay over employment

taxes. 6

Under 26 U.S.C. § 7202,

Any person required under this title to collect,
account for, and pay over any tax imposed by this
title who willfully fails to collect or truthfully
account for and pay over such tax, shall, in addition
to other penalties provided by law, be guilty of a
felony and, upon conviction thereof, shall be fined
not more than $10,000, or imprisoned not more than 5
years, or both, together with the costs of
prosecution.

To secure a conviction under this statute for failure to pay

employment taxes, the government must prove that (1) defendant

has a duty to withhold and pay over employment taxes for the

employer, and (2) defendant willfully failed to perform one of

these tax-related duties. See United States v. Lord, 404 Fed.

6
Boccone also argues that the government failed to charge
him within a three-year statute of limitations period. Boccone,
however, waived this argument by not raising it before or during
trial. See United States v. Williams, 684 F.2d 296, 300 (4th
Cir. 1982). Boccone counters that the government itself has
waived any reliance on waiver by addressing the merits of his
argument in opposition to Boccone’s post-trial motion for
acquittal. But, to the extent this court has recognized such a
“waiver of waiver” argument, it has been in instances of
government “acquiescence” to the issue being raised on appeal.
United States v. Metzger, 3 F.3d 756, 757-58 (4th Cir. 1993).
The government did not so acquiesce in this case, because it
raised Boccone’s waiver in opposition to the motion for
acquittal and raised it again on appeal.

47
Appx. 773, 775 (4th Cir. 2010); United States v. Gilbert, 266

F.3d 1180, 1185 (9th Cir. 2001).

Here, the government introduced substantial evidence to

satisfy both elements of the offense. Concerning Boccone’s

duties, Boccone admitted to a government special agent that he

was responsible for withholding employment taxes from his

employees and for paying over such withholdings to the Internal

Revenue Service. (JA 478). He also had prior experience with

filing payroll tax forms and remitting employment taxes with his

former company, Berwyn Mortgage. (JA 3958-3968). Concerning

Boccone’s failure to pay, Boccone admitted at trial that he was

aware of the obligation to pay employment taxes withheld, and

there was no dispute that Boccone failed to pay the taxes due.

(JA 623, 759).

Boccone suggests, nonetheless, that his failure to pay was

not willful because there was no money available to pay them

when due. Contrary to Boccone’s suggestion, the government

introduced evidence that Chantilly Specialists had sufficient

funds to satisfy the tax obligations or there would have been

sufficient funds had other expenditures not been paid. (JA

4006-4336). “The intentional preference of other creditors

over the United States is sufficient to establish the element of

willfulness.” Turpin v. United States, 970 F.2d 1344, 1347 (4th

Cir. 1992) (internal quotations omitted). Even if other

48
expenditures were necessary for operation of the business, this

does not undermine a finding of willfulness. Indeed, “paying

wages and . . . satisfying debts to creditors in lieu of

remitting employment taxes to the IRS, constitute circumstantial

evidence of a voluntary and deliberate violation of § 7202.”

Lord, 404 F. App’x at 779.

In sum, the government introduced substantial evidence to

support the tax law convictions.

C.

Boccone argues that the prosecutor improperly commented on

his veracity during closing argument. Boccone did not object to

the prosecutor’s closing argument at trial. Accordingly our

analysis is “confined to plain error review.” United States v.

Woods, 710 F.3d 195, 202 (4th Cir. 2013). “Under this standard,

[appellant] must show not only that the district court committed

an error that was plain, but also that the error affected

[appellant’s] substantial rights thereby impacting the outcome

of his trial.” Id. (internal quotations omitted).

The prosecutor’s argument arose out of testimony by Boccone

at trial regarding his provision of a handwriting exemplar

during the investigation of the case. In relevant part, Boccone

testified as follows on re-direct examination:

Q. Did you go in voluntarily on your own to give
[Special Agent Walker] handwriting exemplars?
A. Yes, I did.

49
 Q. Have you gotten any results?
A. No.

(JA 659-60) (emphasis added). During defense counsel’s closing

argument, counsel reminded the jury of this testimony, stating

as follows:

Mr. Boccone took the stand. Told you that he went
voluntarily on his own to Special Agent Walker, and
then for two to three hours give them handwriting
samples. Apparently they were thinking he forged
prescriptions. Now think about it. . . . Who wakes
up and walks off to the police station to give a
handwriting sample if they know that they’ve been
forging prescriptions? He goes in there to give a
handwriting sample.

(JA 781) (emphasis added).

After this argument concluded, the government asked to

correct the record in rebuttal to reflect that the handwriting

exemplar in fact “was done pursuant to a grand jury subpoena.”

(JA 792). Counsel for Boccone thereupon requested an

opportunity to clarify himself “in respect to the handwriting

exemplar, it was pursuant to a grand jury subpoena,” which

request the court allowed. (Id.). At that point, counsel for

Boccone concluded his argument by stating to the jury: “[W]ith

respect to the handwriting exemplars, the grand jury issued a

subpoena for Mr. Boccone to give his handwriting exemplars, and

he went and gave the handwriting exemplars pursuant to the grand

jury subpoena to Special Agent Walker.” (JA 793) (emphasis

added).

50
 Subsequently, upon rebuttal, the prosecution stated as

follows to the jury:

Ladies and gentlemen, we now know that Paul Boccone
gave a handwriting exemplar pursuant to a grand jury
subpoena when he told you during his sworn testimony
that it was voluntarily. What else in Paul Boccone’s
testimony under oath is false, ladies and gentlemen?

(JA 811).

Boccone suggests that this argument was improper because

(1) Boccone in fact testified truthfully that he voluntarily

gave a handwriting exemplar, and (2) the prosecutor’s statement

constitutes an improper expression by the prosecutor as to the

veracity of a defense witness.

With respect to the first challenged statement by the

prosecutor, there was no impropriety in reminding the jury that

Boccone gave the exemplar “pursuant to a grand jury subpoena”

whereas in his testimony he stated that “it was voluntarily.”

(JA 811). This is consistent with the correction made by

Boccone’s own counsel. (JA 793). It is also consistent with the

evidence. In particular, Boccone gave the exemplar after the

investigating attorney informed Boccone’s counsel that the grand

jury had issued a subpoena for the defendant’s handwriting. (JA

938). Boccone was in fact served with the subpoena. (JA 940).

While Boccone points out on appeal that the subpoena was not

served on Boccone until he arrived at the police station, it is

nonetheless accurate to state that the exemplar was given

51
“pursuant to a grand jury subpoena.” (JA 811). Accordingly,

the first challenged statement in the prosecutor’s argument was

not improper.

The second challenged statement in the prosecutor’s

argument, by contrast, may have exceeded the bounds of fair

advocacy. This court has “recognized that it is highly improper

for the government to refer to a defense witness as a liar.”

United States v. Moore, 11 F.3d 475, 481 (4th Cir. 1993); see,

e.g., Woods, 710 F.3d at 202 (prosecutor improperly stated that

defendant “lied . . . under oath when he testified this

morning”). Although the prosecutor did not expressly call the

defendant a “liar,” the prosecutor’s argument clearly

communicated to the jury the prosecutor’s view that defendant

lied under oath.

We need not decide, however, whether the prosecutor’s

argument constituted error. Even assuming that it did, and the

error was plain, we conclude the error did not affect Boccone’s

“substantial rights.” Id. “When the evidence of guilt is

overwhelming and a perfect trial would reach the same result, a

substantial right is not affected by a particular error. Id.

(internal quotations omitted). In undertaking this analysis, we

have considered the following well-established factors:

(1) the degree to which the prosecutor’s remarks have
a tendency to mislead the jury and to prejudice the
accused; (2) whether the remarks were isolated or

52
 extensive; (3) absent the remarks, the strength of
competent proof introduced to establish the guilt of
the accused; and (4) whether the comments were
deliberately placed before the jury to divert
attention to extraneous matters.

Id. (quotations omitted).

Here, accepting that the challenged argument by the

prosecution had a tendency to mislead the jury and prejudice

Boccone, the remarks nonetheless were made in conjunction with

an express correction by Boccone’s own counsel regarding

Boccone’s testimony. Thus, even if the prosecution had not made

the challenged argument, the jury had an independent basis to

question whether Boccone had been fully truthful in his

testimony. In addition, while the remarks came at a prominent

point at the culmination of the closing argument, they were

brief relative to the length of the argument as a whole.

Further, the government’s evidence against Boccone was

overwhelming and was supported by multiple categories of

evidence, each independently supporting the convictions,

including medical records demonstrating Boccone’s involvement in

treatment of patients and the nature of the prescriptions he

directed, testimony from patients, and testimony and records

regarding Boccone’s office practices. Even assuming that

Boccone had not forged prescriptions, sufficient evidence

demonstrated that Boccone conspired to and directed distribution

of controlled substances outside the bounds of medical practice.

53
 Finally, in light of the correction by defense counsel,

there is no indication that the comments were deliberately

placed before the jury to divert attention from the evidence in

this case.

In sum, although part of the challenged prosecution

argument may have been improper, any error resulting therefrom

does not warrant reversal of Boccone’s conviction.

D.

Boccone and Brown challenge the district court’s sentencing

determination. We address first their contention that the

district court failed to adequately explain the sentence given.

“We review a sentence for abuse of discretion.” United

States v. Bell, 667 F.3d 431, 440 (4th Cir. 2011). As part of

this review, we must

“ensur[e] 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—including an
explanation for any deviation from the Guidelines
range.”

United States v. Lynn, 592 F.3d 572, 575 (4th Cir. 2010)

(quoting Gall v. United States, 552 U.S. 38, 51 (2007)).

With respect to the explanation provided by the district

court, “[r]egardless of whether the district court imposes an

above, below, or within-Guidelines sentence, it must place on

54
the record an individualized assessment based on the particular

facts of the case before it.” Bell, 667 F.3d at 442 (quotations

omitted). “The explanation must be sufficient to allow for

meaningful appellate review, such that the appellate court need

not guess at the district court’s rationale.” Id. (internal

quotations omitted). This court previously has observed that

“[w]ithout an affirmative showing the information [in the

presentence report] is inaccurate, the court is free to adopt

the findings of the [presentence report] without more specific

inquiry or explanation.” United States v. Terry, 916 F.2d 157,

162 (4th Cir. 1990) (internal quotations omitted).

In setting forth the reasons for the sentence in this case,

the district court stated as follows with respect to Boccone:

All right. Well, Mr. Boccone, I find the guideline
factors in this case to be properly assessed at a
range of 360 months to life. That because of your
financial condition, the imposition of any fine or
cost is not warranted. But considering your age and
prior record and the nature of this offense, I find
that a sentence somewhat below the guideline range
would be appropriate. It will be the sentence of the
Court that as to Counts, 1 to 5, 7, and 9, you be
committed to the custody of the Attorney General to
serve a term of 180 months . . . .

(JA 1124). The court imposed lesser concurrent terms of

imprisonment for the remaining counts of conviction. For Brown,

the district court stated only:

All right. Well, I find the guideline factors in this
case to be properly assessed at a range of 188 to 235
months. I also find because of your financial

55
 condition, Mr. Brown, that the imposition of any fine
or cost is not warranted. And in considering the
factors under Section 3553, which I must, considering
your – the facts of this case and the extent of your
involvement, I find that a sentence below the low end
of the guideline range would be appropriate. It will
be the sentence of the Court, as to Counts, 1, 2, 7,
and 9, you be committed to the custody of the Attorney
General to serve a term of 60 months . . . .

(JA 1103-04).

The district court’s explanation for the sentence was

lacking in several respects. In particular, the district court

failed to explain adequately the application of each of the

statutory sentencing factors, and to provide “an ‘individualized

assessment’ based on the particular facts of the case before it”

of the basis for the substantial downward variance imposed.

Bell, 667 F.3d at 442. The district court’s cursory reference

to statutory factors, with mention of “age and prior record and

the nature of this offense” for Boccone, and “the facts of this

case and the extent of . . . involvement” for Brown, (JA 1103,

1124), does not explain how these factors for each defendant

apply to warrant a downward variance, leaving us to “guess at

the district court’s rationale.” Bell, 667 F.3d at 442.

In addition, while we can glean from the court’s

explanation that the district court adopted in toto the findings

and conclusions in the presentence report, the district court’s

failure to explain why it did so is procedurally unreasonable.

The district court did not discuss the objections and arguments

56
raised by appellants prior to and during the sentencing hearing,

including their specific contentions that the drug quantity

calculations and corresponding offense level determinations

contained in the presentence reports were not correct, and

Boccone’s objection to application of a sentencing enhancement.

(See JA 1057, 1096, 1117, 4434, 4384).

This court has not previously decided how much “more

specific inquiry or explanation” is required, as suggested by

Terry, 916 F.2d at 162, when a district court adopts findings in

a presentence report over objections and arguments by a

defendant. See United States v. Montes-Pineda, 445 F.3d 375,

380 (4th Cir. 2006) (“[A] district court’s explanation should

provide some indication . . . that the court considered . . .

the potentially meritorious arguments raised by both parties

about sentencing.”). We need not decide this question here,

however. As set forth below, assuming the district court did not

sufficiently explain the sentence imposed, this error is

harmless under the circumstances of this case.

“[P]rocedural errors at sentencing are routinely subject to

harmlessness review.” Lynn, 592 F.3d at 576 (quotations

omitted). When the court commits a procedural error in failing

to explain a sentence given, the government may avoid reversal

if the error “did not have a substantial and injurious effect or

influence on the” result and the court can “say with . . . fair

57
assurance that the district court’s explicit consideration of

[the defendant’s] arguments would not have affected the sentence

imposed.” Id. at 585 (quotations and citations omitted).

In applying this harmless error review, we find persuasive

the court’s treatment of a procedural error in United States v.

Cox, 460 Fed. App’x 248, 250 (4th Cir. 2012). There, the court

reasoned:

In this case, the district court erred by providing no
explanation for the length of the active prison term
it imposed upon Cox. We conclude, however, that the
Government met its burden to show that this error was
harmless. Because Cox received a substantial downward
variance, we conclude the district court's inadequate
explanation ‘did not have a substantial and injurious
effect or influence on the result’ of the sentencing
proceeding. Furthermore, Cox's arguments in support of
a 120–month sentence were without legal merit,
allowing us to conclude with ‘fair assurance that the
district court's explicit consideration of those
arguments would not have affected the sentence
imposed.’

Id. (quoting Lynn, 592 F.3d at 585).

In this case, as in Cox, because appellants received

significant downward variances, the district court’s failure to

adequately explain application of the sentencing factors “did

not have a substantial and injurious effect or influence on the

result” of the sentencing proceeding. Lynn, 592 F.3d at 585

(internal quotations omitted). In addition, the district

court’s failure to set forth reasons for adopting the guidelines

range set forth in the presentence report, including failure to

58
address appellants’ arguments as to the calculation of the

guidelines range, was harmless because these arguments are

without merit, as we set forth below. As such, we may conclude

with “fair assurance that the district court’s explicit

consideration of those arguments would not have affected the

sentence imposed.” Lynn, 592 F.3d at 585 (internal quotations

omitted). 7

Accordingly, we turn next to address appellants’ arguments

as to the guidelines range calculation.

1.

Appellants first argue, as they did before the district

court, that the court incorrectly calculated the drug quantity

7
We find inapposite prior cases, including those cited by
appellants, in which the court has remanded for resentencing
despite the district court’s award of a downward variance. In
those cases, unlike here, the court remanded after finding clear
error in the calculation of a guidelines range. See, e.g.,
United States v. Gomez, 690 F.3d 194, 203 (4th Cir. 2012)
(remanding where district court failed to properly calculate
guidelines range); United States v. Napan, 484 F. App’x 780,
781-82 (4th Cir. 2012) (remanding where the district court
misapplied an enhancement, despite award of downward variance).
Nor does this case involve a variance without explanation in the
direction opposite to that requested by the appellant. See,
e.g., Lynn, 592 F.3d at 582 (remanding where district court
provided “no explanation at all for a substantially above-
Guidelines sentence”); United States v. Engle, 592 F.3d 495, 503
(4th Cir. 2010) (remanding where the government appealed
downward variance imposed without sufficient explanation).

59
used to determine their base offense level under the sentencing

guidelines.

We review “the district court’s calculation of the quantity

of drugs attributable to a defendant for sentencing purposes for

clear error.” United States v. Slade, 631 F.3d 185, 188 (4th

Cir. 2011). In other words, the court must be “left with the

definite and firm conviction that a mistake has been committed.”

United States v. Stevenson, 396 F.3d 538, 542 (4th Cir.2005).

“The Government must prove by a preponderance of the

evidence the amount of controlled substances attributable to a

defendant.” United States v. Carter, 300 F.3d 415, 425 (4th

Cir. 2002). In calculating drug quantity, “a sentencing court

may give weight to any relevant information before it, including

uncorroborated hearsay, provided that the information has

sufficient indicia of reliability to support its accuracy.”

United States v. Crawford, 734 F.3d 339, 342 (4th Cir. 2013)

(quoting United States v. Wilkinson, 590 F.3d 259, 269 (4th

Cir.2010)).

In the context of a drug conspiracy, a “defendant is

responsible not only for his own acts, but also for ‘all

reasonably foreseeable acts’ of his co-conspirators in

furtherance of the joint criminal activity.” Slade, 631 F.3d at

188. A defendant is “accountable for all quantities of

contraband with which he was directly involved and all

60
reasonably foreseeable quantities of contraband that were within

the scope of the criminal activity that he jointly undertook.”

Bell, 667 F.3d at 441 (quoting U.S.S.G. § 1B1.3 cmt. n.2).

According to the presentence report adopted by the district

court, Brown was responsible for the equivalent of 12,453

kilograms of marijuana, based upon 100% of the prescription

amount provided to patients Honesty, Dao, Rogers, and McConnell

after he commenced work at Chantilly Specialists in July, 2009.

(JA 4438). Boccone was responsible for the equivalent of 18,155

kilograms of marijuana, representing the medications prescribed

to Honesty, Dao, and Rogers for the entirety of their care,

under the direction of Boccone. Where these drug weights

exceeded an equivalent of 10,000 kilograms of marijuana, both

Boccone and Brown were subjected to a base offense level of 36.

See U.S.S.G. § 2D1.1.

The evidence presented by the government at trial was

sufficient to establish that Boccone and Brown conspired to

unlawfully distribute controlled substances to Honesty, Dao, and

Rogers, outside the bounds of medical practice and not for a

legitimate medical purpose during the time that they were

involved with treatment of these patients. Whether or not

Boccone or Brown individually saw these patients during each

visit to Chantilly Specialists is not dispositive of the drug

quantity calculation where they each knew, or reasonably should

61
have known, that the entire course of treatment was beyond the

scope of legitimate medical practice. See McIver, 470 F.3d at

563. The illegitimacy of the entire course of treatment is

supported not only by the report and testimony by Dr. Hamill-

Ruth, but also by Boccone’s role in directing the treatment as a

non-medical professional.

In addition, although McConnell’s treatment was not

addressed in the report of Dr. Hamill-Ruth, the government

offered sufficient evidence at trial that Brown treated

McConnell outside the scope of legitimate medical practice, in

disregarding many of the same indicia of abuse and diversion

present with Honesty, Dao, and Rogers. For example, McConnell

did not provide prior treatment records upon beginning treatment

at Chantilly (JA 184), Brown treated McConnell without ever

having given him a physical exam (JA 189), and his prescriptions

increased significantly over time leading to an addiction. (JA

190, 193). In addition, Brown made untoward physical contact

and personal calls to McConnell that impacted the treating

relationship. (JA 192-93). Boccone also was involved in

directing prescriptions. (JA 197-98). The presentence report

noted all these facts, in addition to others obtained based upon

an investigative interview report, regarding adjustments made by

Brown in prescriptions and Brown’s promise to keep prescribing

him 30 milligram oxycodone pills. (JA 4410).

62
 In sum, the drug weight calculation by the district court

properly was supported by an aggregation of quantities of

controlled substances distributed to Honesty, Dao, Rogers, and

McConnell, where treatment of these patients was outside the

scope of legitimate medical practice.

Appellants argue on appeal that the district court’s drug

calculations were erroneous because the court did not follow the

calculation methods set forth by the Fourth Circuit in Bell.

There, defendants pleaded guilty to offenses including

conspiracy to possess with intent to distribute oxycodone, which

they obtained through prescriptions while patients at a pain

management center. Bell, 667 F.3d at 434 & 435. This court

held that the district court did not adequately explain the

basis for the sentence, particularly drug quantity, where the

district court based drug quantity on the amount of

prescriptions received by each patient. Id. at 439-441. The

court noted that, generally, “[w]here there is no evidence that

any of the drugs obtained by members of a conspiracy were

obtained or possessed legally, all reasonably foreseeable

quantities possessed . . . may be considered ‘relevant conduct’

attributable to that defendant.” Id. at 442. But, in “a case

involving a valid prescription,” the court noted,

if . . . the government wishes to use the total
quantity prescribed to one or more conspiracy members
as evidence of the quantity of ‘contraband ... within

63
 the scope of the [conspiracy],’ it must also provide
evidence, and the district court must make a finding,
of something more — for example . . . that the
conspiracy actually distributed a particular amount[,]
[or] that the person who was prescribed the drug
lawfully kept and consumed only a portion (or none) of
the prescribed amount . . . . ”

Id. at 443 (quoting U.S.S.G. § 1B1.3 cmt. n.2). Appellants

contend the district court erred by failing to make any such

findings in this case. We disagree.

Bell is inapposite for several reasons. First, in Bell,

“there [was] no dispute that [defendant] received her pills

using a valid prescription issued to her by physicians at a

single institution.” Id. at 444 (emphasis added). Just the

opposite was true in the present case, where the government

introduced evidence demonstrating that the prescriptions issued

to Dao, Honesty, Rogers, and McConnell were not valid

prescriptions. While appellants contend that these patients

made use of some or most of their prescriptions to provide

relief for their medical conditions, this fact does not

transform an otherwise unlawful prescription issued outside the

scope of medical practice into a valid one.

Second, the defendants in Bell pleaded guilty on the basis

that they, as patients, distributed oxycodone that they had

already received from a pain management center. By contrast,

appellants here were convicted of issuing prescriptions outside

the scope of medical practice. Whether patients in Bell

64
actually ingested the medication could be determinative to

whether they in fact distributed the medication to others. See

id. at 443. Here, by contrast, whether the patients actually

consumed the prescription drugs in question is not itself

determinative of whether the prescriptions were made outside the

scope of medical practice. Indeed, evidence that the patients

in this case ingested excessive quantities of pain medication

over an extended time period was itself an indicia of addiction

further demonstrating illegitimacy of the prescriptions.

Finally, unlike in Bell, the district court in this case

adopted the guidelines range in the presentence report that was

based on a detailed drug quantity calculation as set forth in

the presentence report. In contrast, the district court in Bell

picked a round number below that calculated in the presentence

report, without offering any specific explanation for why that

number was chosen. Id. at 444. Accordingly, the presentence

report in Bell provided no basis, as it did in this case, for

the drug quantity calculation by the district court.

Based on the foregoing, we reject appellants’ argument that

we must vacate the sentence for further fact finding and

explanation regarding the calculation of drug quantity.

Although the district court erred in failing to adequately

explain its reasons for the sentence given, this error was

harmless where we can determine based on the presentence report

65
adopted by the court that there was no clear error in the

calculation of drug quantity.

2.

Boccone challenges the four-point enhancement under §

3B1.1(a), for his role as a leader in the conspiracy. The court

“review[s] a district court’s decision to apply a sentencing

adjustment based on a defendant’s role in the offense for clear

error.” United States v. Sayles, 296 F.3d 219, 224 (4th Cir.

2002).

To qualify for a four-level increase under § 3B1.1(a) of

the Sentencing Guidelines, a defendant must have been “an

organizer or leader of a criminal activity that involved five or

more participants or was otherwise extensive.” § 3B1.1(a).

“Factors the court should consider include the exercise of

decision making authority, the nature of participation in the

commission of the offense, the recruitment of accomplices, the

claimed right to a larger share of the fruits of the crime, the

degree of participation in planning or organizing the offense,

the nature and scope of the illegal activity, and the degree of

control and authority exercised over others.” Id. Application

Note 4.

In applying this enhancement, we look to “whether the

defendant’s role was that of an organizer or leader of people,

as opposed to that of a manager over the property, assets, or

66
activities of a criminal organization.” United States v.

Llamas, 599 F.3d 381, 390 (4th Cir. 2010) (internal quotations

omitted). The enhancement “is appropriate where the evidence

demonstrates that the defendant controlled the activities of

other participants or exercised management responsibility.” Id.

(internal quotations omitted).

For example, in United States v. Ellis, 951 F.2d 580 (4th

Cir. 1991), the court examined application of the enhancement to

a scheme to corruptly secure the passage of legislation in West

Virginia. Although the corrupt scheme involved only four

participants, the court upheld the application of the § 3B1.1(a)

enhancement because the unknowing services of lobbyists,

legislators, and their staffs advanced the criminal activity.

Ellis, 951 F.2d at 585. The court observed that “[i]n

considering whether an activity is ‘otherwise extensive,’ a

court may consider, as it did here, ‘all persons involved during

the course of the entire offense,’ even the ‘unknowing services

of many outsiders.’” Id. (quoting § 3B1.1, cmt. n.2).

In this case, the evidence at trial strongly supported a

determination that Boccone was both the organizer and the leader

of the charged conspiracy to distribute controlled substances.

Although the presentence report does not identify five or more

67
participants in the conspiracy, 8 there is ample evidence that the

criminal activity was extensive. As noted in the presentence

report:

The defendant was the president of Chantilly
Specialists and the owner from December 2005 until
March 2010. He ran Chantilly Specialists’ day-to-day
operations, hired and directed employees, approved
payments by the company, signed payroll checks, and
made financial decisions on behalf of the company.
Additionally, the evidence revealed Boccone, despite
having no medical training or knowledge, saw patients
and made decisions regarding the prescription of
Schedule II controlled substances.

(JA 4362). In addition, although many employees of Chantilly

Specialists may not be culpable enough to be considered

“participants” in the conspiracy, they were still involved as

unwitting providers of support to the conspiracy in allowing

prescription of medications to patients over an extended period

of time without a legitimate medical purpose and outside the

usual scope of medical practice. Likewise, the number of

patients involved, whether those patients were aware of their

abuse or unwittingly receiving illegitimate prescriptions, also

8
The presentence report identifies only three other
participants in the criminal conspiracy, Brown, Dr. Anthony
Fasano, and physician’s assistant Joe Frazier. Although the
government suggests that patients such as Honesty and Dao also
were participants, the presentence report concludes that Boccone
did not direct or manage their activities. In light of our
conclusion above that the criminal activity was “otherwise
extensive,” we need not address here whether the criminal
activity “involved five or more participants.” § 3B1.1(a).

68
augmented the scope and significance of the illegal activity

under leadership of Boccone. Accordingly, because Boccone

exhibited authority and control over both office employees and

patients in furtherance of his criminal activity, the district

court correctly applied the four-level enhancement for Boccone’s

role as a leader in the conspiracy.

In sum, where appellants have not raised any meritorious

arguments impacting the guidelines calculation, and where the

district court awarded a substantial downward departure from the

guidelines range, we find harmless the district court’s error in

failing to explain adequately the sentence given.

III.

Based on the foregoing, appellants’ convictions and

sentences are

AFFIRMED.

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