Abigail Gomez v. Neighborhood Health Partnership, Inc.
Abigail Gomez v. Neighborhood Health Partnership, Inc.
Opinion
USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 1 of 18
NOT FOR PUBLICATION
In the United States Court of Appeals For the Eleventh Circuit ____________________ No. 24-11898 Non-Argument Calendar ____________________
ABIGAIL GOMEZ, Plaintiff-Appellant, versus
NEIGHBORHOOD HEALTH PARTNERSHIP, INC., Defendant-Appellee. ____________________ Appeal from the United States District Court for the Southern District of Florida D.C. Docket No. 1:22-cv-23823-KMW ____________________
Before LAGOA, ABUDU, and WILSON, Circuit Judges. PER CURIAM: Abigail Gomez appeals an order of the district court granting summary judgment to Neighborhood Health Partnership, Inc. (“Neighborhood Health”) in her suit seeking reimbursement for USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 2 of 18
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health care benefits under the Employee Retirement Income Secu- rity Act of 1974, 29 U.S.C. § 1001 et seq. (“ERISA”).1 At bottom, she contends that Neighborhood Health improperly denied her medi- cal claims for reimbursement. After careful review, we affirm. I. FACTUAL BACKGROUND Gomez has an insurance plan with Neighborhood Health.2 Her plan covers certain in-network and out-of-network medically necessary treatments. 3 Prior to 2019, Gomez had undergone three
1 See Gomez v. Neighborhood Health P’ship, Inc., No. 1:22-cv-23823, 2024 WL 2132878
Inc, which is a subsidiary of United Healthcare Services, Inc., an organization which is, in turn, a subsidiary of UnitedHealth Group Inc. (together, “Unit- edHealth”). Portions of the administrative review were performed by Unit- edHealth, but, for consistency, we refer to the appellee and its affiliated enti- ties as Neighborhood Health. 3 Under Gomez’s policy, the insurer deems medically necessary services to be
those: (i) “[i]n accordance with Generally Accepted Standards of Medical Prac- tice”; (ii) “[c]linically appropriate, in terms of type, frequency, extent, service site and duration, and considered effective for [the insured’s] Sickness, Injury, Mental Illness, substance-related and addictive disorders, disease or its symp- toms”; (iii) “[n]ot mainly for . . . convenience or that of [a] doctor or other health care provider”; and (iv) “[n]ot more costly than an alternative drug, ser- vice(s), service site or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as the diagnosis or treatment of [the] Sickness, USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 3 of 18
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different nasal surgeries to address breathing problems and subse- quent unsatisfactory cosmetic and physiological results. In July 2019, Neighborhood Health granted Gomez’s re- quest for coverage of certain medical procedures for her nasal-re- lated health problems under the following CPT codes: 20910, 20912, 30450, and 30465. 4 The authorization form defined
Injury, disease, or symptoms.” The plan then defines “Generally Accepted Standards of Medical Practice” to be “standards that are based on credible sci- entific evidence . . . .” The plan also specifies that Neighborhood Health re- tains “the right to consult expert opinion in determining whether health care services are Medically Necessary.” 4 “CPT codes,” such as these, “are a national uniform coding structure created
for use in billing and overseen by the American Medical Association.” United States v. Moss, 34 F.4th 1176, 1181–82 (11th Cir. 2022). These four codes cor- respond with the following procedures, respectively: (1) cartilage graft; costo- chondral, (2) cartilage graft; nasal septum, (3) rhinoplasty, secondary; major revision (nasal tip work and osteotomies), and (4) repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction). Cf. id. at 1182 (“One type of procedure or service can have more than one CPT code because the same procedure may, in some cases, be more complex than in others.”). Gomez’s plan excludes cosmetic procedures. Under the plan, re- constructive procedures “that correct anatomical Congenital Anomaly with- out improving or restoring physiologic function are considered Cosmetic Pro- cedures.” Rhinoplasties—under Codes 30410 and 30420—are considered re- constructive and medically necessary when seven listed criteria are met, which, broadly speaking, require the insured to show prolonged and signifi- cant symptoms, caused by a nasal obstruction which has been documented photographically and a lack of viable alternative procedures or treatments. Rhinoplasties under Codes 30430, 30435, 30450, and 30400, however, are con- sidered “primarily cosmetic” and are only considered “reconstructive and medically necessary” when five criteria are met, which, broadly speaking, re- quire similar symptoms and documentation. USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 4 of 18
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“medically necessary” as a “service [that] meets accepted standards of medicine and is needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms.” It also stated that, “[a] network provider is a doctor . . . that has a contract with us to pro- vide services or supplies at an agreed upon rate . . . .” Gomez’s plan specifies that Neighborhood Health “require[s] prior authorization for certain [c]overed health [c]are Services” and that “[n]etwork providers are responsible for obtaining prior authorization” before offering services. The plan states that when an insured receives services “from out-of-[n]etwork providers, [the insured] is respon- sible for obtaining prior authorization.” The plan also provides that prior authorization is “made based on the services” the insured actually receives, and if the authorized services differ from the ones actually received, coverage will be offered only for the services pro- vided that are included in the benefits. The preauthorization form designated Dr. Richard Davis as the treating physician. Despite this preauthorization, Dr. Davis de- cided not to perform the procedures because, in his professional opinion, the trauma Gomez’s nose had already experienced made the “risk of complications from cosmetic surgery . . . simply too high.” However, because Gomez wanted to proceed with treat- ment, Dr. Davis referred her to Dr. Jeffrey Epstein. Gomez never sought to amend the preauthorization form to designate Dr. Ep- stein as the treating physician, nor did she submit a completely new health services request. Nevertheless, in October 2019, Dr. Epstein performed a nasal surgery consisting of several procedures and USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 5 of 18
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then billed Neighborhood Health directly using a different set of procedure codes: 30410, 30520, and 30465. 5 In May 2020, Neighborhood Health informed Gomez and Dr. Epstein that this operation was not covered for several reasons, including because it was not “medically necessary,” and the ser- vices billed were different from the services provided—in other words, Dr. Epstein submitted billing codes for services that were not completed. An additional letter provided to Gomez stated that the service she received had “not been proven effective for the doc- umented clinical circumstances” and was “not medically neces- sary,” and was therefore not a covered benefit under the plan. In September 2021, Gomez, through her attorney, requested a review of this determination, submitting a letter outlining the reasons why Neighborhood Health should have provided cover- age, a copy of the original denial documentation, the preauthoriza- tion for Dr. Davis’s procedure, and an operative note from Dr. Ep- stein. In October 2021, Neighborhood Health affirmed its decision and stated that the services she received were cosmetic, rather than medically necessary. Dr. Donald Stepita, a UHC medical director specializing in plastic surgery with a background in general sur- gery, conducted the review and issued the determination.
5 These codes correspond with the following procedures, respectively: (1) rhi-
noplasty, primary; complete, external parts including body pyramid, lateral, and alar cartilages, and/or elevation of nasal tip, (2) septoplasty or submucous resection, with or without cartilage scoring, contouring, or replacement with graft, and (3) repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction). USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 6 of 18
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Dr. Stepita explained that key portions of Dr. Epstein’s operation that would have made the treatment medically necessary—septo- plasty and repair of vestibular stenosis—were not actually per- formed, and that there was a lack of documentation that the re- maining procedures performed would improve physiologic func- tion. Dr. Stepita accordingly agreed with Neighborhood Health’s original denial because the operation Dr. Epstein had performed was cosmetic, not medically necessary, unlike the previously ap- proved procedure. Gomez again appealed the decision. In support of her sec- ond-level appeal, Gomez submitted a letter outlining the reasons she believed Neighborhood Health should change its decision— which used much of the same language as the letter she submitted in her September 2021 appeal—as well as copies of the October 2021 denial letter, the letter from Dr. Davis informing Gomez that he would no longer perform the surgery, the pre-authorization for Dr. Davis’s planned procedure, the original denial letter, notes from Dr. Epstein from the day of the procedure, and follow-up notes. The clinical documentation from Dr. Epstein was limited to one page of billing information with brief diagnosis details, an op- erative note describing the procedure Dr. Epstein performed with the justification for it, and handwritten notes—some of which are fairly illegible. It is clear from his notes, however, that Gomez was “quite unhappy with the esthetic results” of prior surgeries and that the procedure he performed on the tip of her nose was “to create a more esthetic appearance.” Even though Dr. Epstein had submit- ted codes to Neighborhood Health that indicated that a septoplasty USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 7 of 18
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had been performed on Gomez, that procedure was not discussed or mentioned in any of the notes submitted. In November 2022, Neighborhood Health issued a final de- nial of coverage. In this denial, Dr. Christine Haugen—a UHC medical director specializing in plastic and reconstructive surgery with a background in general surgery—once again stated that Gomez’s plan covered medically necessary treatments and that the documentation provided by Dr. Epstein did not reveal completion of a procedure that would make a cosmetic reconstructive surgery medically necessary. Dr. Haugen highlighted other requirements for medically necessary treatments that were not met, including the location where the surgery was performed, 6 and the lack of “a serious medical illness.” II. PROCEDURAL HISTORY After her unsuccessful appeals process with Neighborhood Health, Gomez filed suit in November 2022 in district court. As relevant, her complaint alleged that the denial of benefits discussed
6 United Healthcare’s policies state that “an elective surgical procedure per-
formed in a hospital outpatient department” such as the one where Gomez received her surgery, “is considered medically necessary if there is an inability to access an ambulatory surgical center for the procedure” because there is no geographically accessible ambulatory surgical center (“ASC”) with the needed equipment, no ASC where the insured’s physician has privileges, or an ASC’s specific guidelines prevent the insured from accessing the facility. The final denial letter stated that Gomez’s records did “not show that there were no . . . ASCs . . . in [her] area” and that “[t]hese [services] could have been done at an ASC.” USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 8 of 18
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above constituted a violation of section 502(a) of ERISA. Neigh- borhood Health moved for summary judgment in November 2023, making largely the same arguments it does on appeal—that its de- cision to deny coverage and reimbursement was correct and that there were reasonable grounds to support the denial which were not outweighed by any structural conflict of interest caused by the fact that Neighborhood Health determines eligibility for benefits and pays claims out of its own assets. 7 Gomez also made largely the same arguments in her response to the motion for summary judgment as she does on appeal—that Neighborhood Health’s de- cision was neither correct nor reasonable and that Neighborhood Health had ignored evidence that she was entitled to coverage and had acted arbitrarily by giving multiple explanations for denying coverage. In April 2024, a magistrate judge issued a report and recom- mendation (“R&R”) which recommended that the court grant
7 In the ERISA context, the Supreme Court has explained “the fact that a plan
administrator both evaluates claims for benefits and pays benefits claims cre- ates” a “conflict of interest” relevant to a court’s analysis of the administrator’s decision. Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 112 (2008). Even so, this “pertinent” conflict of interest is just one factor we consider in determining whether a decision is arbitrary and capricious. Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350, 1355 (11th Cir. 2011). Here, we agree with the magistrate judge and district court in finding no evidence that the conflict in this case had “inherent or case-specific importance” sufficient to find Neighborhood Health acted arbitrarily and capriciously. Id. at 1357 (quoting Glenn, 554 U.S. at 117). Accordingly, while the issue weighs into our analysis, as noted below, we do not discuss it at length. USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 9 of 18
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Neighborhood Health’s motion for summary judgment. The mag- istrate judge concluded that Neighborhood Health’s decision “was correct” under de novo review, but that “[n]onetheless, the decision was not arbitrary and capricious even assuming [the] denial was de novo wrong.” The magistrate judge explained there were some dif- ferences between the procedures Dr. Davis originally planned to perform and the ones that Dr. Epstein actually performed. It also found that the plan contained no provision allowing a prior ap- proval for specific health services to automatically transfer to an undesignated treating physician. The R&R also determined Neigh- borhood Health reasonably relied on its reviewing specialists’ opin- ions in denying Gomez’s claim. Overall, the magistrate judge found that Neighborhood Health had followed proper procedures in a reasonable manner, and that its decision was not arbitrary. Gomez objected to the R&R, arguing again that the medical records and coverage guidelines supported her contention that the procedure was medically necessary and that Neighborhood Health and the magistrate judge had ignored that relevant evidence in coming to the opposite conclusion. The district court reviewed the R&R and issued an order affirming and adopting the R&R and granting Neighborhood Health’s motion for summary judgment. Gomez timely appealed. III. STANDARD OF REVIEW “We review the district court’s grant of summary judgment de novo, construing all facts and drawing all reasonable inferences in favor of the non-moving party.” Guevara v. Lafise Corp., 127 F.4th USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 10 of 18
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824, 828 (11th Cir. 2025). “Summary judgment is appropriate when no genuine dispute of material fact exists and a party is entitled to judgment as a matter of law.” Id. at 828–29. “A dispute of fact is genuine if a reasonable jury could return a verdict for the non-mov- ing party.” Id. at 829. IV. DISCUSSION In ERISA cases, our circuit employs the following test when reviewing a plan administrator’s decision regarding an insured’s entitlement to benefits: (1) Apply the de novo standard to determine whether the claim administrator’s benefits-denial decision is “wrong” (i.e., the court disagrees with the administra- tor’s decision); if it is not, then end the inquiry and affirm the decision. (2) If the administrator’s decision in fact is “de novo wrong,” then determine whether he was vested with discretion in reviewing claims; if not, end judicial in- quiry and reverse the decision. (3) If the administrator’s decision is “de novo wrong” and he was vested with discretion in reviewing claims, then determine whether “reasonable” grounds sup- ported it (hence, review his decision under the more deferential arbitrary and capricious standard). (4) If no reasonable grounds exist, then end the in- quiry and reverse the administrator’s decision; if rea- sonable grounds do exist, then determine if he oper- ated under a conflict of interest. USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 11 of 18
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(5) If there is no conflict, then end the inquiry and af- firm the decision. (6) If there is a conflict, the conflict should merely be a factor for the court to take into account when deter- mining whether an administrator’s decision was arbi- trary and capricious.” Blankenship, 644 F.3d at 1355 (italics added) (citing Capone v. Aetna Life Ins. Co., 592 F.3d 1189, 1195 (11th Cir. 2010)); see also Stewart v. Hartford Life & Accident Ins. Co., 43 F.4th 1251, 1254 (11th Cir. 2022). The arbitrary-and-capricious standard is a considerably high one: an administrator’s decision must merely have a reasonable ba- sis. Jett v. Blue Cross & Blue Shield of Ala., Inc., 890 F.2d 1137, 1139 (11th Cir. 1989); see also, e.g., Florida v. HHS, 19 F.4th 1271, 1290 (11th Cir. 2021) (“The arbitrary and capricious standard is ‘exceed- ingly deferential.’” (quoting Miccosukee Tribe of Indians of Fla. v. United States, 566 F.3d 1257, 1264 (11th Cir. 2009))). A plan admin- istrator may accord different weight to the opinions and evidence submitted as part of the review without acting arbitrarily and ca- priciously. Blankenship, 644 F.3d at 1356; see also Black v. Long Term Disability Ins., 582 F.3d 738, 746 (7th Cir. 2009) (“[U]nder our defer- ential standard of review, we must defer to [the plan administra- tor’s] choice between competing medical opinions so long as it is rationally supported by record evidence.”). On appeal, Gomez contends that Neighborhood Health’s decision was incorrect and that the coverage guidelines, if properly applied to her medical records, show that the procedures Dr. Ep- stein performed were medically necessary to address her nasal- USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 12 of 18
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related breathing problems.. She identifies specific language in the plan regarding the various procedure codes to explain why the plan should cover Dr. Epstein’s services. She also repeatedly argues that the fact that Neighborhood Health granted authorization to Dr. Davis was, in and of itself, evidence that she had met the “medically necessary” criteria for nasal surgery. Gomez further contends that the fact that Neighborhood Health offered multiple bases for deny- ing coverage is evidence that its decision was arbitrary and capri- cious. Finally, she argues the district court and magistrate judge failed to address her legal arguments, the “overwhelming evi- dence” in her medical record, and the “inherent nature of ERISA law” in ruling against her. In response, Neighborhood Health argues that Gomez is in- correct that its preauthorization for Dr. Davis justified her expecta- tion that Dr. Epstein’s work would be covered. In support of its decision to deny coverage, it points to its own medical doctors’ medical conclusions regarding Dr. Epstein’s operation, and their determination that the surgery he performed was cosmetic and not medically necessary. Neighborhood Health also asserts that the fact that it had so many reasons for denying her claim was not evi- dence of arbitrariness, but was instead evidence that there were multiple problems with her request. As laid out above, we generally employ a six-step analysis in ERISA cases. See Blankenship, 644 F.3d at 1355. Yet for purposes of resolving this appeal, we need only focus on step three— USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 13 of 18
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reasonableness.8 Even though our review of the district court’s grant of summary judgment is subject to de novo review, the stand- ard applied to the plan administrator’s decision-making is deferen- tial: under the arbitrary and capricious standard we ask only if there was a reasonable basis for the administrator’s decision. Jett, 890 F.2d at 1139; Florida, 19 F.4th at 1290. After carefully reviewing the record, we conclude that Neighborhood Health’s decision to deny Gomez’s coverage request was not arbitrary and capricious. The record shows that Neighborhood Health reviewed Gomez’s medical history and the documents she submitted in sup- port of her administrative appeals. Both Dr. Haugen and Dr. Stepita provided detailed explanations for why the procedures Dr. Epstein performed were not medically necessary or otherwise covered by Gomez’s plan. Without more, Gomez’s bare assertions that Dr. Haugen and Dr. Stepita ignored any supporting evidence in her favor does not equate to arbitrary and capricious decision- making and fails to create a genuine issue of material fact to defeat summary judgment. Guevara, 127 F.4th at 828; Blankenship, 644 F.3d at 1356; see also Paylor v. Hartford Fire Ins. Co., 748 F.3d 8 We have permitted courts to assume, at step one, see Blankenship, 644 F.3d at 1355, that the administrator’s decision was de novo wrong and resolve the case on the remaining steps, see Doyle v. Liberty Life Assurance Co. of Bos., 542 F.3d 1352, 1357 (11th Cir. 2008); see also O.D. v. Jones Lang LaSalle Med. PPO Plus Plan, 772 F. App’x 800, 804 (11th Cir. 2019) (unpublished) (“We need not decide whether UBH’s decision was de novo wrong. Instead, consistent with our precedent, we may assume the decision was de novo wrong in order to reach the discretion question.”). In part, this is the route the magistrate judge and district court followed, and we do so as well. USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 14 of 18
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1117, 1122 (11th Cir. 2014) (“Overcoming [the summary judgment burden] requires more than speculation . . . .”). The plan required Gomez to receive preauthorization prior to undergoing any procedures with Dr. Epstein, an out-of-network provider, if she wanted his services to be covered. Not only did she fail to do so, but she improperly tries to rely on the approval Dr. Davis received to justify her own misstep. However, Gomez’s reliance on the prior approval suffers two significant problems.9 First, Neighborhood Health reasonably concluded that the procedure Dr. Davis was approved to perform was different from the procedure Dr. Epstein actually performed. There was, there- fore, no basis for assuming that an authorization given to an in- network doctor for one procedure would carry over to a different out-of-network doctor for a different procedure. The pre-authori- zation letter identified Dr. Davis, the procedure codes, and the date of authorization and stated that Gomez should contact Neighbor- hood Health if the date the procedure was to be performed or changed. The letter further stated that “the treatment,” as reflected
9 Gomez argues that the R&R improperly supplied a basis for denial of cover-
age that Neighborhood Health did not give: her failure to obtain preauthori- zation. Yet Gomez’s argument in her appeals to Neighborhood Health, as well as in court, has been that Neighborhood Health erred when it failed to consider the pre-authorization issued to Dr. Davis in denying coverage for the procedure Dr. Epstein performed. The R&R correctly acknowledged that the preauthorization was for a different procedure to be performed by a different doctor and thus her arbitrary and capricious argument based on the prior ap- proval is without merit. USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 15 of 18
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by the procedure codes, was medically necessary and covered by the plan. Neighborhood Health’s other communications reflect Gomez’s obligation to update it with relevant information. Moreover, “the treatment” Dr. Davis was approved to per- form was a “blended treatment,” including a medically necessary nasal valve reconstruction as well as elective cosmetic elements. However, Dr. Epstein’s claim to Neighborhood Health used a dif- ferent set of procedure codes, showing that there was a difference between the preauthorization and the surgery performed. Moreo- ver, as Dr. Stepita explained, Dr. Epstein’s notes did not indicate that this reconstruction was performed and suggested, instead, that Dr. Epstein completed purely cosmetic procedures—septal exten- sion grafts and tip grafts. Thus, as Neighborhood Health explained, there is no indication that Dr. Epstein performed the same proce- dure as the one Neighborhood Health initially approved. 10 Accord- ingly, we find unpersuasive Gomez’s attempts to use the pre-au- thorization granted to a different doctor for a different surgery that
10 Neighborhood Health argues that the only code in common between the
two procedures—30465—is a code that is for a cosmetic procedure. That said, we need not resolve this issue. It is relevant, however, that Dr. Davis origi- nally declined to perform the surgery approved—which had cosmetic and non-cosmetic features—because he believed the “risk of complications from cosmetic surgery” were too great. This statement supports Neighborhood Health’s conclusions that the surgery ultimately completed—which did not have the same non-cosmetic purposes as the approved surgery—was primarily cosmetic and not medically necessary under the terms of the plan. USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 16 of 18
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itself was not performed because “the risk of complications from [that] cosmetic surgery . . . [was] simply too high.” Second, and relatedly, Dr. Epstein’s treatment notes did not indicate that he had performed all the procedures he submitted for reimbursement—including, importantly, the procedures that would have made the primarily cosmetic procedure into a “blended” procedure with medically necessary components. See Glazer v. Reliance Standard Life Ins. Co., 524 F.3d 1241, 1247 (11th Cir. 2008) (explaining that an ERISA plaintiff bears the burden to demonstrate they qualify for coverage). Consequently, the admin- istrator did not act arbitrarily in concluding no evidence showed that Dr. Epstein completed a medically necessary procedure. Gomez primarily submitted photos and other documentation of nasal trauma as well as the medical opinion of Dr. Davis that a medically necessary nasal surgery was required to address the on- going symptoms from the original preauthorization. The docu- mentation from Dr. Davis does lend credence to Gomez’s conten- tion that she suffered from significant breathing problems and as- sociated symptoms because of nasal deformities. Even so, just be- cause she previously suffered from symptoms which qualified her for surgery does not mean that she received a medically necessary procedure from Dr. Epstein. Even with this documented history of negative symptoms and the information provided by Dr. Epstein, two different doctors determined that the procedure was not medically necessary, and Dr. Davis’s comments suggested the same. The two doctors who USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 17 of 18
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completed the appeal reviews considered the documentation pro- vided by Gomez but highlighted that, critically, there was no clini- cal documentation that the procedures performed were medically necessary. Blankenship, 644 F.3d at 1354 (“Review of the plan ad- ministrator’s denial of benefits is limited to consideration of the material available to the administrator at the time it made its deci- sion.”). Neighborhood Health did not act arbitrarily by giving weight to these opinions. Id. at 1356; Black, 582 F.3d at 746. Finally, Gomez contends that Neighborhood Health pro- vided shifting bases for their denial of coverage and that these dif- ferent bases constitute “procedural irregularities . . . indicative of arbitrary and capricious decisions.” We do not agree that the rea- sons given were inherently inconsistent but, even if they had been, the minor inconsistencies here do not rise to the level of procedural irregularity suggesting arbitrary and capricious decision-making. See Bloom v. Hartford Life & Acc. Ins. Co., 558 F. App’x 854, 857 (11th Cir. 2014) (unpublished) (“[D]eviations in this case, if indeed there were any at all, were de minimis.”); see also Williams v. BellSouth Telecomms., Inc., 373 F.3d 1132, 1139 (11th Cir. 2004) (concluding that, despite a conflict of interest, the administrator “thoroughly gathered and reviewed medical evidence” in reaching its decision, justifying affirmance), overruled in part on other grounds, as recognized by Blankenship, 644 F.3d at 1354–55. As previously discussed, Gomez’s plan generally excludes cosmetic procedures and only covers medically necessary treat- ments. To establish medical necessity for the procedures she USCA11 Case: 24-11898 Document: 24-1 Date Filed: 09/17/2025 Page: 18 of 18
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sought in this case, Gomez had to satisfy multiple criteria. She had to show that the procedure satisfied the criteria which apply to all medical treatments, to all reconstructive procedures, and to recon- structive rhinoplasties. Glazer, 524 F.3d at 1247. Each of Neighbor- hood Health’s denials included a determination that the procedure was not medically necessary, even when additional criteria were cited as well. The fact that Neighborhood Health identified multi- ple ways that this bar had not been met is not indicative of proce- dural irregularity that points to arbitrary and capricious decision- making, but that Gomez’s request for coverage was deficient on multiple grounds and that Neighborhood Health’s conclusion to that effect was reasonable. See Blankenship, 644 F.3d at 1356. V. CONCLUSION For the reasons we have explained, the district court and the magistrate judge did not err in concluding that there is no genuine material issue of fact as to whether Neighborhood Health acted ar- bitrarily and capriciously. Accordingly, we affirm the order grant- ing summary judgment to Neighborhood Health. AFFIRMED.
Reference
- Status
- Unpublished