Weight Loss Healthcare Centers of America, Inc. v. Office of Personnel Management, 655 F.3d 1202

Walters, a federal employee, had Blue Cross health-plan coverage and received preauthorization for outpatient lap-band surgery by Weight Loss, a non-participating facility.
Weight Loss billed $56,000; Blue Cross paid $1,610 and denied a $6,000 charge for non-covered medical equipment, with a 70% plan-allowance for outpatient non-participating services and a $2,300 stated allowance.
OPM affirmed Blue Cross’s interpretation of the plan, determining Walters’ benefits were correctly paid; Weight Loss sued in district court seeking a ruling requiring payment and detailed reasons for denial.
The district court upheld OPM’s decision; Weight Loss argued OPM’s deferential review was improper and that the plan language was ambiguous and inadequately supported by data.
The Tenth Circuit held that OPM’s plan interpretation warrants deference under arbitrary-and-capricious review but remanded because OPM failed to review the underlying data/calculations used to derive the $2,300 allowance.
OPM’s interpretation was affirmed as reasonable; the court reversed and remanded for further proceedings to address the data-support issue.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether OPM’s deference is proper for FEHBA plan interpretation	Weight Loss argues deference to OPM is inappropriate for contract interpretation.	Blue Cross/OPM rely on FEHBA role and expertise; OPM routinely negotiates and interprets plans nationwide.	OPM interpretation entitled to deference under arbitrary-and-capricious review.
Whether OPM reasonably interpreted the outpatient non-participating allowance	Weight Loss contends the allowance should be the national average for the specific gastric-band outpatient service.	OPM reasonably read the allowance as the national average for outpatient surgical services, not limited to a specific procedure.	OPM's interpretation was reasonable and the most plausible reading of the Plan.
Whether the record supports the $2,300 plan-allowance calculation	Weight Loss argued the data and calculations underlying the $2,300 figure were not provided, hindering verification.	Blue Cross asserted national data existed; OPM did not need to reproduce calculations.	Remand required because OPM failed to explain why the $2,300 figure was correct and did not review supporting data.

Sternberg v. Sec'y, Dept. of Health & Human Servs., 299 F.3d 1201 (10th Cir. 2002) (factors for deference to agency contract interpretation)
Muratore v. OPM, 222 F.3d 918 (11th Cir. 2000) (national uniform interpretation of FEHBA plans; agency expertise)
Nesseim v. Mail Handlers Benefit Plan, 995 F.2d 804 (8th Cir. 1993) (agency interpretation of health plans; arbitrary-and-capricious review)
Burgin v. Office of Pers. Mgmt., 120 F.3d 494 (4th Cir. 1997) (contrasts with deference for contract interpretation)
Caudill v. Blue Cross & Blue Shield, 999 F.2d 74 (4th Cir. 1993) (early deferral to OPM interpretation of health-benefit contracts)
Empire Healthchoice Assurance, Inc. v. McVeigh, 547 U.S. 677 (Supreme Court 2006) (preemption/uniformity in FEHBA plans; scope of FEHBA interpretation)
McMellon v. United States, 387 F.3d 329 (4th Cir. 2004) (en banc; contract-interpretation standards in FEHBA context)