United States of America v. William Lawrence Siefert, M.d. (24-5384); Timothy Ehn, D.c. (24-5385)

RECOMMENDED FOR PUBLICATION
Pursuant to Sixth Circuit I.O.P. 32.1(b)
File Name: 25a0319p.06
UNITED STATES COURT OF APPEALS
FOR THE SIXTH CIRCUIT
UNITED STATES OF AMERICA,
Plaintiff-Appellee,
v.
WILLIAM LAWRENCE SIEFERT, M.D. (24-5384);
TIMOTHY EHN, D.C. (24-5385),
Defendants-Appellants.
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Nos. 24-5384/5385
Appeal from the United States District Court for the Eastern District of Kentucky at Covington.
No. 2:21-cr-00002—David L. Bunning, District Judge.
Argued: June 11, 2025
Decided and Filed: November 24, 2025
Before: GILMAN, DAVIS, and MATHIS, Circuit Judges.
_________________
COUNSEL
ARGUED: Michael Ferrara, DINSMORE & SHOHL LLP, Columbus, Ohio, for Appellant
Siefert. Ronald W. Chapman II, CHAPMAN LAW GROUP, Troy, Michigan, for Appellant
Ehn. Dermot Lynch, UNITED STATES DEPARTMENT OF JUSTICE, Washington, D.C., for
Appellee. ON BRIEF: Michael Ferrara, Lindsay Gerdes, DINSMORE & SHOHL LLP,
Columbus, Ohio, for Appellant Siefert. Ronald W. Chapman II, CHAPMAN LAW GROUP,
Troy, Michigan, for Appellant Ehn. Dermot Lynch, UNITED STATES DEPARTMENT OF
JUSTICE, Washington, D.C., for Appellee.
_________________
OPINION
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DAVIS, Circuit Judge. Timothy Ehn and William Siefert executed a health-care-fraud
scheme at the heart of the opioid epidemic. Ehn owned and operated a pain clinic in northern
>

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Kentucky. With the help of Siefert, Ehn created a testing scheme that involved using patients’
medical conditions as a front to conduct specialized urine drug tests that were billed at a higher
rate than the routine tests most patients needed. This scheme began in 2017 and lasted, for
Siefert, until he stopped working at the clinic in 2019 and, for Ehn, until 2021. Both Ehn and
Siefert were indicted for conspiracy to distribute a controlled substance, health care fraud, and
conspiracy to commit health care fraud. Siefert was also indicted for unlawful distribution of a
controlled substance. A jury ultimately convicted Siefert of health care fraud and Ehn of health
care fraud and conspiracy to commit the same. Both defendants appeal those convictions on
various grounds and challenge the procedural reasonableness of their sentences. For the
following reasons, we AFFIRM.
I. Background
A. Facts
Dr. Timothy Ehn, a chiropractor, owned the Northern Kentucky Center for Pain Relief
(the “Clinic”) and operated its chiropractic wing. The Clinic serviced referral-only patients,
providing them with multiple modalities of treatment, including chiropractic, pain-management,
and injection therapy. And the Clinic offered more medications than just opioids—patients were
prescribed “helper medicines” to decrease their pain. (Trial Tr. Vol. 9, R. 247, PageID 6856).
Ehn hired Dr. William Siefert, a medical doctor, in August 2014 to run the medical side of the
Clinic and to serve as medical director.
As part of its pain-management practice, the Clinic’s doctors used urine drug testing
(“UDT”) to ensure that patients took their medication as prescribed and were not taking
medications or substances that could potentially interact with prescribed opioids. The Clinic
used two types of testing. The first type—presumptive UDT—provides a positive or negative
result to indicate the presence or absence of a particular drug in the urine. The second type—
definitive testing—identifies the concentration of the tested-for drugs in a patient’s system.
The Clinic’s physicians enrolled in multiple insurance programs to serve their patients.
Some insurers, like Medicare, required the enrolled physicians to abide by Medicare laws,
regulations, and program instructions to receive payment for their services. So, to legitimately

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receive reimbursement for UDT services, Siefert and Ehn had to abide by the relevant Medicare
guidelines for UDT. These guidelines, called local coverage determinations (“LCDs”), are
evidence-based policies written and implemented by the local Medicare contractor. Relevant
here, LCDs outline when Medicare will reimburse for UDT.
Medicare regularly reimburses for presumptive UDT because those tests may be
routinely ordered. But definitive tests must be run on complex equipment, making them more
costly to carry out. As a result, they are reimbursed at a much higher rate than presumptive
UDT. And because definitive UDT can test for multiple classes of drugs at once, the tests are
more expensive the more classes of drugs tested. So, Medicare requires documentation
justifying the medical necessity for definitive tests before it will reimburse. This means that
physicians must document why the services were provided for each patient on the date of each
visit, making an individualized assessment of need. Physicians must determine a patient’s
likelihood of straying from his or her pain-management protocol; the more likely a patient is to
deviate, the more often he will need a definitive UDT. A key limitation is that physicians cannot
implement a blanket policy to always order both a presumptive and definitive test—a physician
must determine that the definitive test is medically necessary to use in treating the patient before
ordering it. This includes ensuring that each class of drugs tested for is medically necessary for
the patient’s care.
From 2013 to 2014, the Clinic ran presumptive tests in house but outsourced its definitive
testing to Southwest Labs. During this time, Ehn would tell doctors that they needed to order
both types of UDT for every patient who came in the door. And Ehn profited from these test
referrals, even in the face of concerns from staff that the profits came from illegal testing
practices and kickbacks.
Seeing the profits to be earned from definitive testing, Ehn enlisted Siefert to devise a
new plan. Ehn and Siefert knew that only the lab that was doing the testing could bill for
reimbursement. So, with the help of Karla Cox, the Clinic’s office manager from 2016 to 2019,
they planned to finance an in-house definitive testing machine. This would allow the Clinic to
collect and process both UDT types on site. Cox created a business plan at Ehn’s direction,
using a $215 reimbursement rate per definitive test. That number was based on the highest

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reimbursement level for definitive UDT offered on Medicare’s 2016 fee schedules. Cox used the
highest reimbursement rate because “Ehn said that if we were going to take on bringing in the
lab, we needed to make sure that we ensured that it was the highest level of reimbursement.”
(Trial Tr. Vol. 5, R. 243, PageID 5649). Both Ehn and Siefert agreed to use this reimbursement
rate to calculate the Clinic’s projected revenues, which were then provided to the lenders
financing the new machine. And yet no doctor documented the medical necessity of
presumptively billing every test at the highest reimbursement rate.
As the Clinic was setting up its definitive-testing lab, Ehn’s goal of profiting from lab
tests led to two uncharged over-billing schemes. First, Wellcare—a Kentucky Medicaid
contractor—overpaid by over $2,000 per definitive UDT from January 2016 to May 2017.
Second, insurers overpaid the Clinic for specimen-validity testing from 2016 to 2018. Ehn knew
of these windfalls, but he wanted to remain quiet. Ultimately, the insurers caught the Clinic and
settled any overpayment disputes.
Ehn learned no lessons from these settlements. To maximize profits from the newly
installed definitive-testing machine, Ehn continued to encourage providers to regularly order
both types of UDT for patients. Because Ehn was a chiropractor, he could not prescribe opioids
or order UDT, so he relied on Siefert, who was authorized by the Drug Enforcement
Administration (“DEA”) to prescribe controlled substances, to do so. According to various
Clinic staff members, it was Clinic practice to order a presumptive and a definitive test for each
patient every time they came to the Clinic—once a month per patient. Patient medical records
also reflected this practice. At trial, the government used five patients’ treatment records to
establish Ehn and Siefert’s fraudulent billing scheme. The billing data for these patients showed
that the Clinic billed their insurers monthly for both types of UDT. And the definitive test was
nearly always billed for the most expensive test.
The Clinic’s added profits from in-house definitive testing came with operational
troubles. Because of the definitive UDT machine’s complexity, the Clinic had to hire a qualified
technician to run and maintain it. The Clinic’s first lab technician failed to perform the routine
maintenance necessary to ensure that the machine properly tested the urine samples. That failure
affected the results the machine produced. Indeed, the results of tests run on the malfunctioning

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machine could not be used in patient care because the machine returned false positives, showing
a fatal variety of drugs present in living patients’ systems.
Clinic staff raised concerns to both Siefert and Ehn about the faulty results and the
malfunctioning machine. But even after Ehn observed the machine malfunctioning and agreed
that it was malfunctioning, the Clinic continued to use it for testing without changing testing
practices. The Clinic even billed insurers for tests run on the malfunctioning machine and kept
the profits.
On August 23, 2018—two years after the Clinic began processing its own definitive
tests—Siefert wrote a memo to Ehn reflecting his realization that the Clinic was likely over-
testing patients without documenting the medical necessity for the tests. Siefert stated that the
Clinic “need[ed] to be doing a risk stratification” before deciding to order any definitive UDT.1
(Trial Tr. Vol. 5, R. 243, PageID 5707). He also acknowledged that the Clinic might need to
reimburse insurers for potential over-billing. Cox weighed in with a memo of her own, reporting
Medicare’s requirement that providers document the rationale for each definitive test
administered. That rationale must focus on the patient’s needs and substances relevant to his or
her treatment. She cited Medicare guidelines explaining risk stratification and cautioned that
definitive tests are rarely needed absent a limited set of circumstances, like an unexpected
presumptive result.
Ehn responded to these memos by having Cox perform an internal audit of the Clinic’s
patients to conduct after-the-fact risk stratification. To control the amount of repayment
necessary, Ehn specifically told Cox that the audit should reveal a higher percentage of high-risk
patients and a lower percentage of low-risk patients. But Ehn was a chiropractor, not a medical
doctor, and lacked any authority or training to order UDT, so his directions were not grounded in
professional medical judgment. And a patient’s risk level must be established on a patient-by-
patient basis, not based on predetermined risk categorization. Yet nearly all patients received a
high-risk classification, limiting the Clinic’s cost of repayment for over-testing and allowing it to
continue testing the vast majority of patients every month.
1In the context of UDT, risk stratification involves “looking at a patient’s individual risk level for abuse” of
opioids and other drugs. (Id. at 5705).

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Siefert left the Clinic in early 2019. By that time, the Clinic had lost its latest lab
technician. Finding no one to run the definitive UDT machine, Ehn ran it himself with assistance
from an outside contractor. But Ehn did not have time to work as a full-time chiropractor and
run the machine, so he fell behind on preparing urine samples and running tests. This resulted in
samples being left untested beyond their shelf lives, so Clinic staff had to discard some. The
Clinic fell so behind on maintenance that it had to outsource testing once again because
definitive UDT results from the Clinic’s machine could not be trusted. The government
executed a search warrant on the Clinic in the summer of 2020. After this, Ehn continued to
process definitive tests. But he could not overcome the accumulated backlog, and many urine
samples were not tested in time or at all, meaning providers could not use the results to treat
patients. These late-processed tests were not medically necessary because the results were
unreliable and could not be used in treating patients. Yet the Clinic still billed for them.
B. Procedural History
A grand jury charged both defendants with conspiracy to commit health care fraud, in
violation of 18 U.S.C. § 1349 (Count 13) and health care fraud, in violation of 18 U.S.C. § 1347
(Counts 14–15). These counts alleged that the defendants engaged in a fraudulent UDT scheme
to over-bill insurers. The indictment also charged both defendants with conspiracy to distribute
controlled substances, in violation of 21 U.S.C. § 846 (Count 1), and charged Siefert with eleven
specific instances of unlawful distribution of a controlled substance, in violation of 21 U.S.C.
§ 841(a)(1) (Counts 2–12). Both defendants elected to exercise their jury-trial right. Each orally
moved for a directed verdict of acquittal at the close of the government’s case. The district court
denied both motions.
The jury found Siefert guilty of health care fraud and Ehn guilty of both conspiracy to
commit health care fraud and health care fraud. Both defendants renewed their motions for
acquittal and moved for a new trial under Federal Rules of Criminal Procedure 29 and 33 after
the jury returned its verdict. The district court denied both motions, finding there was “ample,
competent and admissible evidence presented for a reasonable jury to” convict. (Mem. Op. and
Order, R. 280, PageID 8218). Both defendants’ pre-sentencing reports (“PSRs”) calculated their
total offense levels as 37 with a criminal history category of I. After adjudicating the parties’

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objections to the PSRs, the district court calculated a total offense level of 24 for Siefert and 26
for Ehn. This gave Siefert a Guidelines range of 51 to 63 months’ imprisonment and Ehn a
range of 63 to 78 months. The court sentenced both defendants well below their respective
Guidelines ranges: 18 months for Siefert and 30 months for Ehn.
Both defendants appeal various aspects of their convictions and sentences. Ehn argues
that there was insufficient evidence to support either of his convictions. He further claims that
the district court improperly admitted propensity evidence. He also challenges the district
court’s denial of his requested jury instruction on LCDs. He claims that the government
materially varied from the fraud charged in the superseding indictment. He next contends his
conflict-of-interest waiver was constitutionally invalid. Lastly, he claims that the district court
improperly calculated the loss and restitution amounts, rendering his sentence procedurally
unreasonable.
Siefert raises two challenges on appeal. First, he claims that the government’s
introduction of uncharged patient death evidence amounted to prosecutorial misconduct,
rendering his trial fundamentally unfair. Second, like Ehn, Siefert claims the district court
procedurally erred in calculating the amount of loss attributable to him.
II. Sufficiency of the Evidence
We first address Ehn’s sufficiency-of-the-evidence challenges. Ehn claims that the jury
lacked sufficient evidence to support either of his convictions. We review Ehn’s challenges de
novo. United States v. Ray, 803 F.3d 244, 262 (6th Cir. 2015). We ask “whether any rational
trier of fact could have found the elements of the offense beyond a reasonable doubt.” United
States v. Sumlin, 956 F.3d 879, 891 (6th Cir. 2020) (quoting United States v. Maliszewski, 161
F.3d 992, 1005 (6th Cir. 1998)). To prevail, Ehn must establish that no rational juror could have
found the government met its burden on either charge. Ehn’s burden is a heavy one because we
examine “the evidence in the light most favorable to the government and draw all inferences in
the government’s favor.” Id. (quoting Maliszewski, 161 F.3d at 1005). In so doing, we also
draw all inferences and resolve any credibility determinations in favor of preserving the jury’s
verdict. Id.

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A.
We begin with Ehn’s health-care-fraud conviction. To prove Ehn committed that
offense, the government had to show that Ehn “knowingly (1) devised and (2) executed a scheme
to defraud a healthcare benefit program (3) with intent to defraud.” United States v. Betro, 115
F.4th 429, 443–44 (6th Cir. 2024) (citation omitted); 18 U.S.C. § 1347. Evidence presented at
trial amply satisfies the government’s burden.
Ehn knew that Medicaid and Medicare would reimburse only for medically necessary
definitive testing. After all, he agreed to abide by Medicaid and Medicare regulations, which
explained that each would reimburse only for medically necessary care. Yet his instructions to
Clinic staff about testing practices disregarded those regulations. The regulations clearly state
that, to receive reimbursement for testing, doctors must document the medical necessity of
definitive testing for each patient and the classes of drugs to be tested. But the Clinic often billed
and received payment for definitive testing with no documented need for a definitive test, let
alone one that tests for the maximum number of drug classes. And the Clinic billed tests run on
malfunctioning equipment even though those tests were unreliable and thus not medically
necessary. Indeed, Ehn knew that the definitive machine was malfunctioning, but he did nothing
to stop the Clinic from billing for the unreliable, medically unnecessary tests the machine
produced. Instead, Ehn micromanaged billing practices and encouraged providers to over-test
their patients in an effort to use definitive UDT to increase the Clinic’s profits. And Ehn had no
training or expertise to discern whether these tests were medically necessary; as a chiropractor,
he was not authorized to prescribe opioids or order UDT.
Despite his lack of expertise, Ehn ignored concerns that the Clinic was testing too
frequently. Even when Siefert told Ehn that the Clinic had been over-testing and needed to
engage in risk stratification, Ehn asked Cox to run an internal audit with results showing
primarily high-risk patients to limit repayment. But Ehn could not have known whether patients
were high or low risk, or whether those tests were medically necessary.
Ehn’s consistent choice to put UDT profits above ensuring that insurers paid only for
Clinic patients’ medically necessary care readily supports his health-care-fraud conviction.

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After all, the government need not present “[d]irect evidence of fraudulent intent” to defeat
Ehn’s sufficiency challenge. Betro, 115 F.4th at 444 (alteration in original) (quoting United
States v. Anderson, 67 F.4th 755, 770 (6th Cir. 2023) (per curiam)). The jury could have inferred
Ehn’s guilt from his instructions to bill for the highest level of care even if that care was not
medically necessary. See id. at 444–45. Or from the fact that he allowed the Clinic to bill for
tests run so long after collecting the sample that it could no longer rely on the provider’s
certification that the tests were medically necessary when ordered. See United States v. Bertram,
900 F.3d 743, 749 (6th Cir. 2018). So, too, would Ehn’s desire to maximize profits (shown
through the 2016 business plan) or to skew the 2018 audit results to high-risk patients have been
sufficient for the jury to infer fraud.
Ample testimony from Clinic employees and expert witnesses explained how UDT
should have been used at the Clinic and when insurers would reimburse for definitive UDT.
Testimony also established that Ehn strayed from those parameters at nearly every opportunity.
Drawing all inferences in the government’s favor, as we must, see Sumlin, 956 F.3d at 891, the
record shows that the Clinic ordered and billed for UDT greatly exceeding what Ehn should have
known Medicare and Medicaid would reimburse for. From this, the jury could have inferred that
Ehn knowingly and intentionally devised and executed a health-care-fraud scheme to over-bill
for medically unnecessary UDT, in violation of 18 U.S.C. § 1347.
B.
Ehn’s challenge to his conspiracy conviction fares no better. To prove Ehn engaged in a
conspiracy to commit health care fraud, the government had to show that “two or more persons
conspired, or agreed, to commit the crime,” and “that the defendant knowingly and voluntarily
joined the conspiracy.” United States v. Rogers, 769 F.3d 372, 377 (6th Cir. 2014) (citation
omitted); 18 U.S.C. § 1349. The government readily established that an agreement existed
through circumstantial evidence tending to show both Siefert and Ehn agreed to participate in the
common scheme. See United States v. Hughes, 505 F.3d 578, 593 (6th Cir. 2007).
The same evidence supporting Ehn’s health-care-fraud conviction also shows that the
jury reasonably convicted him of conspiracy to commit health care fraud. The 2016 business

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plan shows that Ehn and Siefert intended to bring definitive testing in house and to bill for those
tests at the highest reimbursement level to maximize the Clinic’s profits, notwithstanding the fact
that no medical need could justify that plan. And Ehn and Siefert agreed to share the profits such
testing brought in, again with no regard to whether they lawfully obtained those proceeds from
insurers. Drawing all inferences in the government’s favor, a jury could have found that Ehn and
Siefert agreed to engage in a conspiracy to commit health care fraud.
What little Ehn argues on the merits—that he merely trusted Siefert’s medical judgment
in ordering tests—ignores the substantial evidence showing his involvement in ordering and
billing UDT to maximize the Clinic’s (and, in turn, his) profits. Ehn’s primary argument is a
legal one: He argues that the rule of consistency bars his conviction because the jury acquitted
Siefert of the same charge. This common law rule “at one time required ‘that, where all possible
co-conspirators are tried together, and all but one are acquitted, the remaining conspirator’s
conviction must be reversed for lack of sufficient evidence.’” United States v. Crayton, 357 F.3d
560, 564 (6th Cir. 2004) (quoting United States v. Walker, 871 F.2d 1298, 1304 n.5 (6th Cir.
1989)). However, this rule is no longer good law after United States v. Powell, 469 U.S. 57
(1984). See Getsy v. Mitchell, 495 F.3d 295, 306–07 (6th Cir. 2007) (en banc) (acknowledging
abrogation of the rule). So “the acquittal of all but one co-conspirator during the same trial does
not necessarily indicate that the jury found no agreement to act.” Crayton, 357 F.3d at 565.
Because the rule of consistency is no longer good law, Ehn is left with no argument to challenge
his conspiracy conviction.
III. Rule 404(b) Propensity Evidence
Next we consider Ehn’s argument that the district court erroneously allowed the
government to present “[s]ignificant and unfairly prejudicial evidence” of his prior conduct.
(ECF 19, Ehn’s Br. at 33). Ehn challenges the government’s introduction of evidence that Ehn
(1) accepted kickbacks from Southwest Labs, (2) settled an overpayments dispute with Wellcare,
and (3) resolved a double-billing dispute concerning specimen-validity testing. The district court
found the proposed evidence was “admissible to establish the defendants’ knowledge, intent,
[and] lack of mistake pursuant to 404(b).” (Pre-trial Hr’g Tr., R. 157, PageID 3107). The court
provided a limiting instruction to the jury, allowing it to “consider the evidence only as it relates

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to . . . Ehn’s plan, motive, intent, or knowledge.” (Jury Instrs., R. 218, PageID 3712). We
review the district court’s decision to admit Rule 404(b) evidence under a modified abuse-of-
discretion standard. United States v. Fairley, 137 F.4th 503, 517 (6th Cir. 2025). “First, we
review for clear error the factual determination that other acts occurred,” and then “we review de
novo the legal determination that the acts were admissible for a permissible 404(b) purpose.” Id.
(quoting United States v. Adams, 722 F.3d 788, 810 (6th Cir. 2013)). Finally, “we review for
abuse of discretion the determination that the probative value of the evidence is not substantially
outweighed by unfair prejudicial impact.” Id. (quoting Adams, 722 F.3d at 810–11).
Federal Rule of Evidence 404 prohibits the use of prior-acts evidence “to prove a
person’s character in order to show that on a particular occasion the person acted in accordance
with the character.” Fed. R. Evid. 404(b)(1). However, it allows such evidence to show
“motive, opportunity, intent, preparation, plan, knowledge, identity, absence of mistake, or lack
of accident.” Fed. R. Evid. 404(b)(2).
The district court acted within its discretion in allowing the government to present this
evidence. Ehn does not dispute that these prior acts occurred. And the evidence of these prior
acts is probative of a material issue other than character because it “relates to conduct that is
substantially similar and reasonably near in time to the specific intent offense at issue.” United
States v. Barnes, 822 F.3d 914, 922 (6th Cir. 2016) (citation omitted). It tends to show that,
immediately before or concurrently to the fraud scheme charged, Ehn knew how to use UDT to
fraudulently increase profits and had the motive and intent to keep ill-gotten gains from over-
billing insurers. And the district court allowed the government to present the challenged
evidence to combat Ehn’s good-faith defense of inadvertent over-billing—a material issue other
than Ehn’s character. Lastly, Ehn does not explain how this evidence was unduly prejudicial. If
anything, Ehn claims in his reply brief that the instruction was confusing. But the instruction
specifically identified the other-acts evidence introduced, explained what the jury had to find to
consider those acts, and limited the purpose for which the jury could consider the acts. Thus, the
instructions faithfully followed the rule explaining when other-acts evidence is admissible,
mitigating any potential prejudice to Ehn. See United States v. Bartholomew, 310 F.3d 912, 922
(6th Cir. 2002).

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IV. LCD Jury Instruction
We move next to Ehn’s contention that the district court erroneously denied his requested
LCD jury instruction. As part of its argument that Siefert and Ehn billed for UDT while
intentionally disregarding the relevant Medicaid and Medicare standards for reimbursement, the
government introduced expert testimony regarding the relevant LCDs that determined when the
Clinic could seek Medicare reimbursement for UDT. Ehn contends that, through this testimony,
the government tried to prove that he committed fraud by violating LCDs because the
government’s case rested on the definition of “medically necessary,” which LCDs define. So,
according to Ehn, a limiting instruction was necessary to ensure that the jury did not convict Ehn
based solely on his violation of any LCDs. The proposed instruction would explain the limited
role of LCDs in the Medicare-reimbursement process and inform the jury about how a provider
could appeal the accuracy of an LCD.
The district court rejected Ehn’s proposed instruction, reasoning that it “leads to
confusion” and does not involve definitions that the jury will be asked to decide. (Charge Conf.
Tr., R. 326, PageID 8906). We review that decision for abuse of discretion. Anderson, 67 F.4th
at 764. We may reverse “only if the proposed instruction is (1) a correct statement of the law,
(2) not substantially covered by the charge actually delivered to the jury, and (3) concerns a point
so important in the trial that the failure to give it substantially impairs the defendant’s defense.”
United States v. Volkman, 797 F.3d 377, 385 (6th Cir. 2015) (internal quotation marks and
citation omitted).
We need go no further than the first prong of this test to determine that no abuse of
discretion occurred here. Ehn’s proposed instruction incorrectly states the law. The instruction
states that “decision-makers at every level of the appeal process can decline to apply the local
coverage determination. Thus the only person or entity bound by a local coverage determination
is the contractor that issued it.” (Proposed Instrs., R. 214, PageID 3667). This is incorrect.
When Ehn agreed to serve Medicare patients, he entered a contract binding himself to abide by
the relevant Medicare rules and LCDs issued by Medicare contractors. So regardless of the
LCD-appeal structure, Clinic staff, including Ehn, were required to abide by LCDs when billing.
And LCDs are binding unless superseded by an administrative law judge on appeal of the denial

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of a claim or by rulemaking from the Department of Health and Human Services. See Agendia,
Inc. v. Becerra, 4 F.4th 896, 902 (9th Cir. 2021). So the instruction incorrectly states that only
the contractor who issued the LCD is bound by it.
In any event, the proposed instruction does not reflect the point of law that Ehn contends
that the district court should have instructed the jury on. Nothing in the instruction clearly
conveys to the jury that criminal liability may not be imposed simply because Ehn violated an
LCD. The district court was correct in concluding that this instruction would “lead[] to
confusion” because it does not inform the jury on things it would be called upon to consider.
(Charge Conf. Tr., R. 326, PageID 8906). Ehn provides no argument to persuade us otherwise.
Because he cannot meet even the first prong of this test, the district court did not abuse its
discretion in denying the proposed instruction.
V. Material Variance
Ehn next argues that the government materially varied from the indictment to convict him
of both health care fraud and conspiracy to commit health care fraud. He claims that the
superseding indictment alleged only that he orchestrated a scheme of fraud premised on billing
insurers for medically unnecessary tests. But, according to Ehn, the government’s theory at trial
shifted to prove that Ehn committed a different fraud scheme premised on billing for tests run on
a broken machine and billing for useless delayed tests. This different theory, says Ehn,
prejudicially varied from the conduct charged in the indictment.
We review claims of “variances from an indictment de novo.” United States v. Mize, 814
F.3d 401, 408 (6th Cir. 2016) (citation omitted). “[A] variance is ‘not per se prejudicial.’” Id. at
409 (quoting United States v. Budd, 496 F.3d 517, 521 (6th Cir. 2007)). It occurs “if the
evidence ‘proves facts materially different from those alleged in the indictment.’” United States
v. Davis, 970 F.3d 650, 659 (6th Cir. 2020) (quoting Budd, 496 F.3d at 521). We will reverse
only if Ehn demonstrates that “(1) a variance occurred and (2) that the variance affected” his
substantial rights. Mize, 814 F.3d at 409 (quoting United States v. Kuehne, 547 F.3d 667, 683
(6th Cir. 2008)). A defendant’s substantial rights “are affected only when the defendant shows
prejudice to his ability to defend himself at trial, to the general fairness of the trial, or to the

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indictment’s sufficiency to bar subsequent prosecutions.” Kuehne, 547 F.3d at 683 (quoting
United States v. Hynes, 467 F.3d 951, 962 (6th Cir. 2006)).
Ehn has shown no such variance. The indictment clearly charged Ehn with a single
health-care-fraud scheme committed through various means from 2017 through 2021. And it
charged a single conspiracy to carry out that scheme from 2017 through 2019. The indictment
alleges that Ehn executed the scheme to defraud by knowingly submitting claims for payment for
“medical services that were not performed or were not medically necessary[.]” (Superseding
Indictment, R. 58, PageID 346). It identified specific definitive UDT billed (most at the highest
reimbursement level) in violation of 18 U.S.C. § 1347. The “methods, manner, and means” used
to carry out the conspiracy and health-care-fraud scheme included: (1) submitting claims to
health-benefit programs for UDT insurance reimbursement; (2) directing Clinic employees to
obtain urine samples during office visits; (3) performing both presumptive and definitive UDT
on the specimens regardless of patients’ individualized needs pursuant to a secret “blanket
order”; (4) submitting “false and fraudulent claims” for UDT reimbursement and falsely
representing that the tests were medically necessary; (5) submitting bills for definitive UDT at a
higher level of complexity than medically necessary; and (6) causing the submission of bills for
definitive UDT not used to treat patients. (Id. at 340–41). These allegations adequately notified
Ehn of the charges brought against him and the facts through which the government intended to
prove its case.
Start with the substantive health-care-fraud charge. The stated method, manner, and
means of fraud put Ehn on notice that the scheme could involve any number of medically
unnecessary tests, including those conducted on broken machines. After all, neither Medicare
nor Medicaid would reimburse for those useless tests. The indictment even identified specific
tests billed in violation of federal law. Several of those tests were conducted either while the lab
technician failed to properly maintain the machine from 2017 to 2018 or when Ehn fell behind in
running the definitive tests in 2020. Ehn was on notice that he would need to defend against the
government’s contention that these tests either were not performed or were medically
unnecessary. That the government’s evidence at trial went into further detail about how and why
those tests were not performed or were medically unnecessary (i.e., because they were performed

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on broken machinery or too long after the sample had been collected) does not mean the
government varied from the indictment. After all, “[t]he presentation of additional evidence to
substantiate charged offenses . . . does not constitute facts materially different from those
charged in the indictment.” Kuehne, 547 F.3d at 686. The fraud scheme charged was the same
regardless of which specific evidence the government used to prove it.
Next consider Ehn’s conspiracy conviction. At trial, the government sought to prove that
Siefert and Ehn agreed to execute a UDT scheme to maximize the Clinic’s profits and their
personal profits. The scheme involved over-testing and over-billing by requiring both
presumptive and definitive UDT for every patient at every visit, billing at the highest
reimbursement level even when it was not medically necessary, and billing for testing on
malfunctioning equipment. This mirrors the conspiracy alleged in the indictment. We will find
a variance in conspiracy cases only where “the indictment alleged one conspiracy, but the
evidence can reasonably be construed only as supporting a finding of multiple conspiracies.”
Adams, 722 F.3d at 805–06 (alteration in original) (quoting United States v. Caver, 470 F.3d
220, 236 (6th Cir. 2006)). Ehn does not identify any other conspiracy alleged at trial; his qualms
focus only on the different means that the government raised for how he and Siefert executed
their scheme. But proving the conspiracy using different means is not the same as varying from
the indictment. Because the indictment encompassed all relevant evidence that the government
presented to prove the crimes of conviction, Ehn’s variance challenge fails.
VI. Conflict of Interest
The last of Ehn’s pre-sentencing challenges concerns the conflict-of-interest waiver he
signed. Prior to trial, the government raised a potential conflict of interest regarding Ehn’s trial
counsel. Ehn’s chosen trial counsel, Squire Patton Boggs (US) LLP, had represented Wellcare
of Kentucky (now owned by Centene Corp.) in its overpayment dispute and settlement with the
Clinic and represented Centene—which helps run Kentucky Medicaid—throughout the trial.
Ehn’s attorney responded to the government’s notice, dispelling any concerns that the firm’s
conflict would impact his performance in this case. The district court held a conflict-of-interest
hearing, where Ehn stated his desire to keep his retained trial counsel. Ehn signed a written
waiver acknowledging the same.

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Ehn now claims that the representation of Wellcare by his trial-counsel’s firm “prevented
counsel from fully exploring the Wellcare issue at trial, significantly hindering Dr. Ehn’s trial
defense” and deprived him of his Sixth Amendment rights. (ECF 19, Ehn’s Br. at 57). Whether
Ehn’s conflict waiver was constitutionally valid and whether the district court properly
concluded that no conflict existed are both legal questions that we review de novo. United States
v. Osborne, 402 F.3d 626, 630 (6th Cir. 2005). But we review the factual findings underlying
the district court’s legal conclusions for clear error. Id.
To remedy any conflict-of-interest concerns, a court “must be convinced that the
defendant[] understand[s] the rights being waived and the consequences of the waiver of those
rights.” Id. at 631 (citing Fed. R. Crim. P. 44(c)). In other words, a binding conflict waiver must
be “knowing, intelligent, and voluntary.” Id. at 630 (citation omitted). In determining whether
the district court adequately informed the defendant of his right to conflict-free counsel, we
consider whether the court explained the hazards of representation by the conflicted attorney and
informed him of his right to unconflicted counsel. Id. at 631. This includes whether the court
ensured that the defendant “has discussed the matter with his attorney or if he wishes with
outside counsel.” Fed. R. Crim. P. 44(c) advisory committee’s note to 1979 amendment (citation
omitted).
Ehn knowingly, intelligently, and voluntarily waived any conflict. At the conflict-of-
interest hearing, Ehn affirmed that he discussed the conflict issue with his counsel, understood
that counsel could not use any information that his firm learned while representing Wellcare
against him, declined independent representation on the conflict issue three separate times, and
chose to retain his counsel. Further, he signed a conflict waiver recognizing his right to conflict-
free counsel in which he acknowledged the potential conflict of interest and expressed his “wish
to continue with [his] current counsel.” (Conflict Waiver, R. 163, PageID 3149). The waiver
concludes with Ehn’s acknowledgement that he is “making this decision knowingly and
voluntarily.” (Id.). Considering all this evidence, Ehn waived his right to challenge the
constitutionality of his counsel’s representation. See Osborne, 402 F.3d at 630.

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VII. Prosecutorial Misconduct
A.
We now turn to Siefert’s prosecutorial misconduct claim. Before trial, Siefert filed a
motion in limine to exclude evidence of seven uncharged patient deaths. The government
intended to use the evidence to show that Siefert and Ehn knew that their prescribing methods
harmed patients and led to overdose deaths, yet they continued to prescribe in that manner
anyway. It would also show, according to the government, that Siefert lied to the medical board
when he said that he “never had a patient overdose and die during [his] many years of practice.”
(Trial Tr. Vol. 3, R. 241, PageID 4991). The district court denied the motion, determining that
“targeted” evidence could be relevant to show Siefert’s knowledge that the patients were
possibly misusing their prescriptions. (Pre-trial Hr’g Tr., R. 157, PageID 3040). The court
reasoned that such evidence could support the government’s theory that continuing to issue
prescriptions was outside the scope of usual professional practice or for no legitimate medical
purpose—i.e., that he was prescribing in an unauthorized manner. See Ruan v. United States,
597 U.S. 450, 454 (2022) (holding that the government must prove that an authorized medical
prescriber, in issuing controlled substances, knowingly or intentionally acted in an unauthorized
manner).
The district court acknowledged that “Ruan didn’t change the rules of evidence,” but
reasoned that circumstantial evidence about the patients’ deaths was “critical” for the
government to meet its burden under Ruan. (Id.). Therefore, said the district court, the probative
value of the evidence was “not substantially outweighed by the danger of unfair prejudice.” (Id.
at 3042). Nonetheless, to minimize the risk of any potential unfair prejudice, it adopted a
limiting instruction providing that the jury could consider evidence of death only “for the
purpose of [determining] the defendant’s knowledge, [or] intent, and that the distribution of the
prescriptions were or were not outside the scope of professional practice or not for legitimate
medical purpose[s].” (Id.).
At trial, the government presented evidence about all seven patients’ deaths. For
instance, one expert opined that Siefert’s prescribing methods contributed to the patients’ deaths.

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And family members of some the deceased patients testified that their loved ones showed signs
of addiction while in Siefert’s care. But it offered specific evidence of Siefert’s knowledge of
the deaths of only three patients. Therefore, as a curative measure, the court instructed the jury
to disregard death-related evidence “[i]f the defendant did not know about certain evidence of
deaths,” because that evidence would “not [be] relevant to that defendant’s knowledge” for the
distribution counts. (Trial Tr. Vol. 2, R. 240, PageID 4697).
In denying Siefert’s post-trial motion for acquittal or new trial, the district court clarified
that the prosecution “was not required to prove that Defendants were aware of each death for the
evidence of the patient deaths to be relevant.” (Mem. Op. and Order, R. 280, PageID 8212).
Instead, it emphasized that the evidence of patient deaths was relevant if it had “some tendency
to suggest that a provider defendant knew or was deliberately ignorant of the fact that patients
might be misusing prescriptions and overdosing.” (Id. (quoting United States v. Hofstetter, No.
3:15-cr-27, 2019 WL 6718489 (E.D. Tenn. Dec. 9, 2019)). Considering the limiting instruction
that it provided to the jury, the district court found that the prosecution did not violate the court’s
pretrial order, and even if it had, vacatur was not warranted. After all, the jury acquitted Siefert
of the drug distribution counts for which the challenged evidence was admitted. Accordingly, it
denied Siefert’s motion for acquittal or new trial.
Siefert challenges the district court’s decision on appeal, leaning heavily on his assertion
that the evidence of patient deaths was “irrelevant and prejudicial.” (ECF 15, Siefert’s Br. at 37).
Specifically, he argues that the government violated the district court’s pretrial order by offering
evidence of the other four patients’ deaths without having a good-faith belief that it could show
Siefert’s knowledge of the deaths. In proceeding in this fashion, says Siefert, the government
committed misconduct entitling him to a new trial.
B.
Generally, we review questions of prosecutorial misconduct de novo. United States v.
Gardiner, 463 F.3d 445, 459 (6th Cir. 2006). The government argues that plain-error review
applies here because Siefert failed to raise his misconduct objection during trial. True, Siefert
objected to the government’s use of patient death evidence solely on evidentiary grounds during

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trial. But Siefert contends that he still preserved his misconduct objection because he raised the
issue in post-trial proceedings in the district court, and the court addressed it in a post-trial order.
Although the government points to caselaw stating that failure to lodge a misconduct objection
during trial means that the issue receives plain-error review on appeal, see, e.g., Betro, 115 F.4th
at 447, the cases it relies on for this proposition involve instances where the objecting party
failed to raise the issue with the district court at any stage. Less clear is the standard to be
applied when, as here, the specific objection was not raised during trial but was later ruled upon
by the district court. Regardless, we need not resolve this disagreement because we conclude
that Siefert’s objection fails under any applicable standard. Cf. United States v. Pacheco, Nos.
23-5762, 5819, 2025 WL 2060779, at *4 (6th Cir. July 23, 2025).
C.
“We employ a two-step test in evaluating a claim of prosecutorial misconduct.” United
States v. Carson, 560 F.3d 566, 574 (6th Cir. 2009). First, we ask whether the challenged
statement or action was improper. Id. If it was improper, we next consider whether the conduct
was flagrant, warranting reversal. Id. Because Siefert has not shown that the government’s
actions were improper, he fails at step one.
Siefert makes four interrelated arguments. According to him, the government acted
improperly by: (1) defying the court’s pre-trial order concerning the use of uncharged death
evidence; (2) introducing evidence relating to patient overdose deaths despite lacking a good-
faith basis for doing so; and (3) introducing irrelevant and prejudicial death-related evidence. He
also claims that (4) he is entitled to a new trial because the “cumulative effect” of the
prosecution’s misconduct deprived him of due process. (Id. at 23). The district court rejected
these arguments, as do we.
As an initial matter, the district court did not forbid the introduction of death-related
evidence absent a showing of Siefert’s direct knowledge. Rather, the court allowed for the
possibility that the government could show constructive knowledge or deliberate ignorance.
True, there was seeming incongruity between the district court’s pre- and post-trial orders.
Pretrial, the district court said that the government was “going to have to show that

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[the defendants] knew about the deaths,” while post-trial it stated that the government “was not
required to prove that Defendants were aware of each death for the evidence of the patient deaths
to be relevant.” (Pre-trial Hr’g Tr., R. 157, PageID 3035; Mem. Op. and Order, R. 280, PageID
8212). Still, we reject Siefert’s invitation to read the pretrial order as a hard-and-fast prohibition
against the introduction of death-related evidence absent a direct knowledge link. Had the
district court meant to bar the introduction of such evidence, it would have granted Siefert’s
motion to exclude it. Indeed, all parties knew during the pretrial conference that the government
did not have direct evidence establishing Siefert’s knowledge of four of the seven patient deaths.
But that fact alone did not render all evidence of “red flags” irrelevant for the drug distribution
counts. So Siefert’s contention that “[b]ecause [direct] evidence simply did not exist, the
government’s conduct must be viewed as deliberate” is off base. (Siefert’s Br. at 34–35). At no
point did the district court find that the government violated its pretrial order. Nor do we.
With this clarification in mind, Siefert’s good-faith argument buckles. He asserts the
government lacked “good faith” because it had no reason to “believe that it could meet the
knowledge burden[.]” (Id. at 30). Yet, Siefert points us to no specific actions to show that the
government lacked a reason to believe that it could show that Siefert knew of or deliberately
ignored evidence of patient deaths. Rather, he seems to argue that the government’s failure to
definitively show that Siefert knew about four of the deaths is evidence of bad faith in and of
itself. But we do not automatically equate this lack of direct proof with a lack of good faith. As
noted, the government had previewed evidence of patient deaths at the pretrial hearing, and the
district court indicated that “[t]he knowledge . . . described here by the United States is
sufficient” for introduction of the evidence. (Pre-trial Hr’g Tr., R. 157, PageID 3042). Under
these circumstances, the government’s inability to ultimately show Siefert’s knowledge does not
constitute lack of good faith.
Next, we agree with the district court that the evidence relating to patient deaths was
relevant and not unduly prejudicial. Siefert resists this conclusion by tethering relevance to
Siefert’s knowledge of the deaths. But relevance under Ruan involves a different kind of
“knowledge”: the mens rea with which the government must prove Siefert acted when issuing
prescriptions. Ruan, 597 U.S. at 457–58. To satisfy Ruan, evidence of patient overdose deaths

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can be relevant to questions of whether the doctor knew or had reason to know that his
prescribing practices were unauthorized and whether he intended to prescribe in an unauthorized
manner. Introduction of evidence for this end was not improper.
Siefert’s prejudice argument also fails. As discussed, the district court expressly
instructed the jury to consider death-related evidence only on the issue of Siefert’s knowledge or
intent—and even then, only to the extent that Siefert knew or should have known of the deaths.
Subject to narrow exceptions not applicable here, “our legal system presumes . . . that jurors
follow limiting instructions[.]” Samia v. United States, 599 U.S. 635, 646 (2023). And here
there is no reason to conclude that they did not. While such instructions are not “a sure-fire
panacea” to mitigate prejudice, we agree with the district court that Siefert “c[ould not] show that
he was prejudiced by the admittance of this evidence.” United States v. Haywood, 280 F.3d 715,
724 (6th Cir. 2002); (Mem. Op. and Order, R. 280, PageID 8213). After all, the jury acquitted
Siefert of every count to which the death-related evidence was relevant. This makes Siefert’s
suggestion that the evidence was so prejudicial that it could have infected the jury’s decision
making as to the health-care-fraud count speculative at best.
In sum, we agree with the district court that the prosecution did not act improperly. As
discussed above, the government planned to offer the patient-death evidence to prove knowledge
for purposes of the drug counts. At trial, all parties agreed that the government had offered
circumstantial evidence that Siefert knew that three of the seven patients had died. And because
the government was unsuccessful in its effort to link Siefert by knowledge or deliberate
ignorance to the other four patients’ deaths, the district court curtailed the government’s ability
to reference them during closing. Siefert points to no examples of the government disregarding
this admonition. Accordingly, we see no impropriety in the government’s actions. And because
the government did not act improperly by offering evidence relating to uncharged patient deaths,
we end our prosecutorial-misconduct analysis at step one.
Finally, Siefert argues that he deserves a new trial because the “cumulative effect” of the
prosecution’s misconduct deprived him of due process. (ECF 15, Siefert’s Br. at 23). We
review the district court’s denial of his motion for acquittal or new trial on this basis under the
abuse-of-discretion standard. See United States v. Pierce, 62 F.3d 818, 823 (6th Cir. 1995). On

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this front, we ask whether the alleged improper conduct “so infected the trial with unfairness as
to make the resulting conviction a denial of due process.” Slagle v. Bagley, 457 F.3d 501, 515
(6th Cir. 2006) (quoting Darden v. Wainwright, 477 U.S. 168, 181 (1986)). Isolated errors that
“might not be so prejudicial as to amount to a deprivation of due process . . . may cumulatively
produce a trial setting that is fundamentally unfair.” United States v. Hernandez, 227 F.3d 686,
697 (6th Cir. 2000) (citation omitted).
Because we find that the government did not engage in even isolated instances of
misconduct, we agree with the district court that Siefert is not entitled to a new trial. See United
States v. Trujillo, 376 F.3d 593, 614 (6th Cir. 2004). Like the district court, we note that the
death-related evidence implicated only charges for which Siefert was acquitted.2 Siefert insists
that the introduction of the death-related evidence affected the jurors’ decision-making on the
health care fraud scheme. But he points us to no facts tending to demonstrate such a correlation.
And any overlap between the offenses is not obvious. For these reasons, we find that the district
court did not abuse its discretion by denying Siefert’s due process claim.
VIII. Sentencing Reasonableness
Lastly, we address Siefert and Ehn’s challenges to the reasonableness of their sentences.
Both defendants challenge the district court’s calculation of the respective loss amounts
underlying their Guidelines ranges.3 These amount to challenges to the procedural
reasonableness of the defendants’ sentences. See United States v. Rayyan, 885 F.3d 436, 440
(6th Cir. 2018). We review procedural reasonableness under the abuse-of-discretion standard.
2In a footnote, Siefert presses his evidentiary arguments. (ECF 15, Siefert’s Br. at 28 n.5). But, even were
we to agree with Siefert’s argument that unfair prejudice outweighed the probative value of the death evidence
concerning the four patients about whom the government failed to establish knowledge, any such error would be
harmless beyond a reasonable doubt, because Siefert has not shown that this evidence affected the jury’s verdict.
See, e.g., United States v. Suarez, 263 F.3d 468, 484 (6th Cir. 2001) (finding “no sign” that inadmissible evidence
related to a charge for which the defendant was acquitted—but unrelated to the charges for which he was
convicted—was “so damaging to him as to have had a substantial and injurious effect or influence in determining
the jury’s verdict” (citation modified)).
3Ehn also challenges the district court’s restitution calculation because it did not factor in repayments to
Wellcare and was not based on an audit to ensure all tests were billed erroneously. These claims fail because the
court expressly discounted the settlement repayments from the restitution amount. And the restitution amount was
calculated by subtracting any repayments from the total amount paid by insurers for definitive UDT (minus the
twenty-percent discount for any valid tests).

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Betro, 115 F.4th at 454. But we review the district court’s factual determination of the amount
of loss under the clear-error standard and its methodology for arriving at that amount de novo.
Id.
A.
The Federal Sentencing Guidelines enhance “a defendant’s sentence to correlate to the
amount of loss caused [by] his fraud.” United States v. Triana, 468 F.3d 308, 319 (6th Cir.
2006). We calculate the amount of loss as “the greater of actual or intended loss.” Betro, 115
F.4th at 454 (quoting United States v. Wendlandt, 714 F.3d 388, 393 (6th Cir. 2013)). “‘[A]ctual
loss’ is ‘the reasonably foreseeable pecuniary harm that resulted from the offense[.]’” Triana,
468 F.3d at 320 (quoting U.S.S.G. § 2B1.1 cmt. (n.2(A)(I) and (ii)) (2002)). When, like here, the
losses stemming from financial frauds are difficult to quantify, “the district court need only make
a reasonable estimate of the loss, given the available information.” Id. (citation omitted). “Such
estimates need not be determined with precision.” Id. (internal quotation marks and citation
omitted). But the district court must “actually find facts, and it must do so by a preponderance of
the evidence.” United States v. White, 492 F.3d 380, 416 (6th Cir. 2007) (emphasis omitted).
B.
Ehn and Siefert argue that the burden to prove the loss amount remained on the
government because the district court did not make a finding that the fraud was pervasive.
Because of that, say the defendants, the government had to prove and the district court had to
find the reasonable estimated loss by a preponderance of the evidence. They also argue that the
district court’s calculation and methodology was flawed, and that it failed to articulate a
reasonable method for calculating the loss amount as required by U.S.S.G. § 2B1.1.
The district court found the loss amount by a preponderance of the evidence and
explained its loss calculation at sentencing. The defendants’ presentence reports from the
probation department followed U.S.S.G. § 2B1.1 to calculate the loss amount: The sum was
reached by first determining the total amount billed for the definitive tests and then subtracting
twenty percent to account for any legitimate tests. So, the total loss amount was around
$47 million for Siefert and around $53 million for Ehn.

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Both the defendants and the government objected to this loss calculation, agreeing that
the amount paid by insurance, not the amount billed, should serve as the basis for the calculation.
The district court agreed that the loss calculation should use the paid amount. It adopted the
remainder of the probation department’s methodology, though, subtracting twenty percent from
the paid amount to account for legitimate definitive tests. The court noted that “virtually every
patient . . . received both a presumptive and a definitive test” irrespective of whether the patient
had an unexpected result. (Sent. Hr’g Tr., R. 323, PageID 8711). The court reasoned that
calculating loss based only on definitive UDT—which the evidence showed were nearly always
ordered in a fraudulent manner—avoided any objections regarding presumptive tests because
presumptive UDT is often medically necessary. And the court reduced the loss and restitution
amounts further to account for the settlement repayment to Wellcare in 2019, making the loss
amount attributable to Siefert $1,968,765.69 and to Ehn $4,079,182.93. This was a “reasonable
estimate of the loss[.]” Triana, 468 F.3d at 320.
Ehn and Siefert claim that this determination lacks any basis because the district court did
not explain or justify why it found the twenty percent reduction appropriate to reasonably
estimate the loss amount. We disagree. That number is supported by defendants’ own expert.
The expert testified that definitive testing may sometimes be medically necessary, but only at a
rate of one to two tests per patient per year. That rate is approximately eight or sixteen percent
of the Clinic’s testing rate. Extrapolating from that, at most sixteen percent of the Clinic’s tests
were medically necessary. So, discounting twenty percent of the amount paid for definitive tests
more generously credits Siefert and Ehn for potentially necessary testing. Based on the
information available, this was a reasonable estimate of the financial loss accumulated from the
defendants’ fraud. See id. at 319–20. So, the district court did not clearly err in calculating each
defendant’s loss amounts, and the sentences are procedurally reasonable.
IX. Conclusion
We AFFIRM.

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