Eleventh Circuit Upholds Insurer’s Denial of Nasal Surgery Coverage as Not Medically Necessary

In Gomez v. Neighborhood Health Partnership, Inc., No. 24-11898, 2025 WL 2658881 (11th Cir. Sept. 17, 2025), the Eleventh Circuit affirmed a district court decision granting summary judgment to Neighborhood Health Partnership, Inc. (“Neighborhood Health”), rejecting Gomez’s claim for coverage under ERISA for a nasal surgery she underwent in 2019. The Eleventh Circuit held that Neighborhood Health reasonably denied coverage for Gomez’s surgery because she failed to obtain proper preauthorization, the procedures performed were materially different from those originally approved, and the medical record did not establish that the surgery was medically necessary under the plan. Applying the deferential arbitrary and capricious standard, the court found the insurer’s decision rational and supported by substantial evidence.

Gomez, insured through a Neighborhood Health plan, sought treatment for longstanding breathing problems and complications from prior nasal surgeries. Her insurer preauthorized surgery with Dr. Richard Davis, approving certain procedure codes that included both reconstructive and cosmetic elements. Dr. Davis ultimately declined to perform the surgery, citing the high risk of complications. Gomez instead sought care from Dr. Jeffrey Epstein, who performed a different set of procedures without obtaining new preauthorization.

When Dr. Epstein billed Neighborhood Health, the insurer denied coverage, finding the procedures not medically necessary and largely cosmetic. Two separate medical directors reviewing the case confirmed that Dr. Epstein’s operation lacked documentation of medically necessary components, such as septoplasty, and was instead performed for esthetic improvement.

After exhausting Neighborhood Health’s internal appeals, Gomez filed suit under ERISA § 502(a). The district court, adopting a magistrate judge’s recommendation, granted summary judgment for Neighborhood Health. The court found that the insurer’s denial was both correct under de novo review and reasonable under the deferential arbitrary and capricious standard.

The Eleventh Circuit affirmed the district court’s decision because Neighborhood Health’s denial of benefits had a reasonable basis in the administrative record and was not arbitrary or capricious. Although Gomez argued that preauthorization for Dr. Davis’s surgery established medical necessity for Dr. Epstein’s procedures, the court rejected that position. It explained that the surgeries were not the same and that plan rules required Gomez to seek separate authorization for treatment with an out-of-network physician.

The court also emphasized the absence of clinical documentation supporting Gomez’s position. Dr. Epstein’s notes reflected a primarily cosmetic focus, and his billing codes did not align with the procedures actually performed. Two reviewing physicians concluded the surgery lacked medically necessary components, and the court found no evidence that Neighborhood Health acted unreasonably in relying on those expert assessments.

Finally, the panel addressed Gomez’s claim that the insurer gave shifting explanations for denial. The court concluded that the reasons provided were not inconsistent, but rather multiple independent grounds showing why her claim failed under the plan’s terms. The court held that the minor variations across communications did not amount to procedural irregularities that would suggest arbitrary decision-making. Accordingly, the panel affirmed the district court’s grant of summary judgment in favor of Neighborhood Health.