Dorothy Garner v. Central States, Southeast and Southwest Areas, 31 F.4th 854

Dorothy Garner underwent cervical spine surgery on February 5, 2019 after an MRI and neurosurgeon Henry Elsner recommended surgery to address worsening back/neck pain.
Garner’s insurer (Central States) denied coverage (~$90,000) under the plan’s “medically necessary” requirement.
Central States obtained an independent medical review (IMR) from Dr. Francesco Serafini but failed to provide him the MRI report and Dr. Elsner’s office notes; Serafini concluded the surgery was not necessary based on the incomplete file.
On appeal Central States obtained a second IMR from Dr. Brad Ward, who had the full record and also found the surgery not medically necessary, citing lack of documented neurologic abnormalities and purported absence of conservative treatment beyond medication.
The trustees relied on both IMRs and denied benefits; the district court granted Garner summary judgment, and the Fourth Circuit affirmed, holding the trustees abused their discretion and upholding the district court’s award of benefits.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Did trustees abuse their discretion by relying on an IMR prepared without critical records?	Garner: Yes — Serafini lacked MRI and treating notes, so reliance was arbitrary.	Central States: No — Serafini’s IMR was only part of the process; later review cured any defect.	Held: Abuse of discretion — trustees improperly relied on Serafini’s incomplete IMR when denying benefits.
Could trustees impose a conservative-treatment prerequisite to coverage?	Garner: No — plan contains no such precondition and she had tried postural exercises.	Central States: Lack of conservative treatment supported denial.	Held: Abuse of discretion to impose an extratextual mandatory requirement; conservative treatment may be a factor but not a plan term.
Was remand required or was awarding benefits appropriate?	Garner: Award benefits — trustees had multiple opportunities and showed unwillingness to fairly consider evidence.	Central States: Remand would allow correction of procedural defects.	Held: District court did not abuse discretion in awarding benefits rather than remanding.
Did trustees satisfy "reasoned and principled" review under ERISA abuse-of-discretion standard?	Garner: No — process was arbitrary and lacked substantial evidence.	Central States: Decision was reasonable and supported by IMRs.	Held: No — trustees failed to engage in deliberate, principled reasoning and lacked adequate support.

Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989) (ERISA review framework and trustee discretion)
Booth v. Wal-Mart Stores, Inc., 201 F.3d 335 (4th Cir. 2000) (plan administrator must use reasoned and principled decisionmaking)
Ellis v. Metropolitan Life Ins. Co., 358 F.3d 307 (4th Cir. 2004) (abuse-of-discretion standard requires deliberate, principled reasoning and substantial evidence)
Berry v. Ciba-Geigy Corp., 761 F.2d 1003 (4th Cir. 1985) (where trustee lacks adequate evidence remand is proper)
Helton v. AT & T Inc., 709 F.3d 343 (4th Cir. 2013) (standard for district court’s discretion to remand ERISA claims)
Bernstein v. Capital Care, Inc., 70 F.3d 783 (4th Cir. 1995) (reversal rather than remand appropriate for clear fiduciary error)
Jones v. Metropolitan Life Ins. Co., 385 F.3d 654 (6th Cir. 2004) (administrator cannot add eligibility requirements not in plan)
Miller v. United Welfare Fund, 72 F.3d 1066 (2d Cir. 1995) (trustees who manifestly refuse fair consideration should not get remand)