Appellate Case: 22-4082 Document: 010110963219 Date Filed: 12/05/2023 Page: 1
`FILED
`United States Court of Appeals
`Tenth Circuit
`
`December 5, 2023
`
`Christopher M. Wolpert
`Clerk of Court
`
`
`PUBLISH
`
`UNITED STATES COURT OF APPEALS
`
`FOR THE TENTH CIRCUIT
`
`
`
`
`
`No. 22-4082
`
`IAN C.; A.C.,
`
` Plaintiffs - Appellants,
`
`v.
`
`UNITEDHEALTHCARE
`INSURANCE COMPANY,
`
` Defendant - Appellee.
`
`------------------------------
`
`CHAMBER OF COMMERCE OF THE
`UNITED STATES OF AMERICA,
`
` Amicus Curiae.
`
`Appeal from the United States District Court
`for the District of Utah
`(D.C. No. 2:19-CV-00474-HCN)
`
`Brian Smith King of Brian S. King P.C., Salt Lake City, Utah, for Plaintiffs -
`Appellants.
`
`Amanda Shafer Berman of Crowell & Moring LLP, Washington, D.C. (Amy M.
`Pauli, Neil Nandi, and Samuel H. Ruddy of Crowell & Moring LLP,
`Washington, D.C., and Jennifer S. Romano of Crowell & Moring LLP, Los
`Angeles, California, with her on the brief) for Defendant - Appellee.
`
`Tara Morrissey, U.S. Chamber Litigation Center, Washington, D.C.; Meaghan
`VerGow, O’Melveny & Myers LLP, Washington, D.C., filed an amicus curiae
`brief on behalf of Defendant - Appellee, for the United States of America.
`
`
`
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`

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`Appellate Case: 22-4082 Document: 010110963219 Date Filed: 12/05/2023 Page: 2
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`Before BACHARACH, PHILLIPS, and EID, Circuit Judges.
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`PHILLIPS, Circuit Judge.
`
`
`
`
`
`This appeal arises from an action under the Employee Retirement Income
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`Security Act of 1974 (ERISA), 29 U.S.C. §§ 1001–1461, to challenge the denial
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`of healthcare benefits through an employer-sponsored plan. Ian C., the plan
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`participant, claimed coverage for his son, A.C., the beneficiary, to receive care
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`at an inpatient residential treatment center, Catalyst Residential Treatment, for
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`mental-health and substance-abuse issues. The plan authorized
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`UnitedHealthcare Insurance Company (United), the claims fiduciary, to
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`determine A.C.’s eligibility for benefits under the plan.1 After initially covering
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`A.C.’s treatment at Catalyst, United later denied coverage.
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`Ian C. internally appealed the adverse benefit determination, which
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`United upheld on appeal. Ian C. then pursued his case against United in federal
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`district court, where he alleged that United’s denial violated his right to receive
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`a “full and fair review” of his claim under 29 U.S.C. §§ 1133(2), 1104(a)(1).2
`
`
`1 United administered benefits for mental-health and substance-abuse
`services through its designee, United Behavioral Health. We refer to these
`entities collectively as “United.”
`
` 2
`
` Ian C. and A.C. are both named plaintiffs on the complaint filed in the
`U.S. District Court for the District of Utah and are both named as appellants on
`the notice of appeal to this court. But for concision, we refer to the appellants
`collectively under the guise of “Ian C.,” as the covered plan participant and
`parent of the claimed beneficiary.
`
`
`
`2
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`

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`Appellate Case: 22-4082 Document: 010110963219 Date Filed: 12/05/2023 Page: 3
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`Ian C. argued that United arbitrarily and capriciously denied benefits to A.C.
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`by failing to address A.C.’s substance abuse as an independent ground for
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`coverage, by determining that A.C.’s continued treatment at Catalyst was not
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`medically necessary, by ignoring the opinions of A.C.’s medical providers, and
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`by misapplying the appropriate level-of-care guidelines. United denied these
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`claims, and the parties filed competing motions for summary judgment. Ruling
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`on dual motions for summary judgment, the district court decided in favor of
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`United. Ian C. now appeals the district court’s ruling that United’s decision to
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`deny benefits was not arbitrary and capricious and complied with ERISA.
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`Exercising jurisdiction under 28 U.S.C. § 1291, we agree with Ian C. that
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`United’s decision to deny benefits was arbitrary and capricious. We hold that
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`United’s denial violated 29 U.S.C. § 1133(2) and the ERISA regulations that
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`guarantee a “full and fair review” of claims raised under § 1132(a)(1)(B), and
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`so we reverse.
`
`I.
`
`Factual Background
`
`A.
`
`Ian C.’s Plan
`
`BACKGROUND
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`Ian C.’s employer-sponsored benefits plan provides that United may
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`decide “whether [the] Benefit plan will pay for any portion of the cost of a
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`health care service,” “[i]nterpret Benefits and the other terms, limitations and
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`exclusions set out in [the plan],” and “[m]ake factual determinations relating to
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`Benefits.” App. vol. 8, at 13. The plan covers services for mental health and
`3
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`Appellate Case: 22-4082 Document: 010110963219 Date Filed: 12/05/2023 Page: 4
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`substance abuse, specifically treatment at a residential treatment facility. But
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`even these ostensibly covered services must be “[m]edically [n]ecessary” for
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`United to extend benefits. Id. at 40, 45. And only United, or its designee, may
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`determine medical necessity at its discretion.
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`To determine which services are medically necessary, United follows
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`level-of-care guidelines for each area of service that it covers. For example, the
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`guidelines for Common Criteria and Clinical Best Practices (Common Criteria
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`Guidelines) establish general standards for admission, continued coverage, and
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`discharge at a residential treatment facility. United also has more specific
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`guidelines tailored to services for mental health and substance abuse—
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`guidelines for the Mental Health Residential Treatment Center (Mental Health
`
`Guidelines) and guidelines for Substance-Related Disorders (Substance Abuse
`
`Guidelines).
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`The Common Criteria Guidelines advise United to cover a beneficiary’s
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`admission to a residential treatment facility if “the member is eligible for
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`benefits,” and the “member’s current condition cannot be safely, efficiently,
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`and effectively assessed and/or treated in a less intensive level of care.” App.
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`vol. 9, at 33–34. For United to cover “continued service,” the Guidelines
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`recommend that the “admission criteria continue to be met and active treatment
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`is being provided.” Id. at 34. And the Guidelines direct United to stop service
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`and discharge the beneficiary when the “factors which led to admission have
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`been addressed” and “the member can be safely transitioned to a less intensive
`4
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`Appellate Case: 22-4082 Document: 010110963219 Date Filed: 12/05/2023 Page: 5
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`level of care.” Id. at 35. The Mental Health Guidelines and Substance Abuse
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`Guidelines incorporate the Common Criteria Guidelines by reference.
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`Ian C.’s plan also provides a process for appealing adverse benefit
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`determinations. Upon receiving a claim denial, the plan allows Ian C. to appeal
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`the decision to United within 180 days. United then assigns the decision to be
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`reviewed by a “qualified individual . . . who was not involved in the prior
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`determination.” App. vol. 8, at 61. If the appeal is denied, then the decision is
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`final and the internal appeals process is exhausted.
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`B.
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`A.C.’s Treatment History
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`A.C. was seventeen when Catalyst admitted him for mental-health and
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`substance-abuse treatment, but these problems had dogged him since childhood.
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`A.C. was diagnosed with Attention Deficit Hyperactivity Disorder at age seven.
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`This diagnosis put him on medication for the first time, which caused him to
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`feel withdrawn and not like himself. A.C. struggled with schoolwork through
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`elementary and middle school, which strained his relationship with his parents.
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`At thirteen, clinical psychologist Dr. Walter Peacock diagnosed A.C. with
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`Anxiety Disorder. Dr. Peacock began meeting regularly with A.C. and his
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`family to manage A.C.’s anxiety and “unhealthy relationship” with his parents.
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`App. vol. 3, at 52. This outpatient therapy proved unsuccessful. By high school,
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`A.C. was habitually experimenting with drugs, including marijuana, cocaine,
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`Xanax, and Klonopin, and drinking alcohol almost daily. These addictions
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`escalated during A.C.’s high school years, leading to an overdose in December
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`2015.
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`The overdose was a tipping point for A.C. Dr. Peacock attested that
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`A.C.’s “pattern of behavior was growing more and more dangerous,” making
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`inpatient treatment the only viable option. Id. at 52, 53. And so, given A.C.’s
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`persistent recalcitrance and unwillingness to participate in therapy, Dr. Peacock
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`recommended to Ian C. and his wife that they admit A.C. to an inpatient
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`wilderness program.
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`A.C. began treatment at one such program, Blue Fire Wilderness, on
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`April 7, 2016. He was admitted for “Attention-Deficit/Hyperactivity Disorder,”
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`“Alcohol Use Disorder,” and “Unspecified Depressive Disorder.” Id. at 56. At
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`Blue Fire, A.C. participated in group therapy sessions, which sometimes
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`focused on drug use and addiction. Halfway through A.C.’s stay at Blue Fire,
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`Dr. Jeremy Chiles conducted a psychological evaluation of A.C. Regarding
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`A.C.’s substance-use history, Dr. Chiles noted that A.C. began drinking alcohol
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`at fourteen, which devolved into daily alcohol use by his junior year in high
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`school.3 His evaluation states that A.C. had experimented with a slew of other
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`drugs, including marijuana, LSD, Xanax, cocaine, codeine, hydrocodone, and
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`mushrooms. Id. at 96. Dr. Chiles portrayed A.C.’s drug use as a coping
`
`
`3 Dr. Chiles stressed that “since [A.C.] was interviewed, he disclosed to
`his therapist at [Blue Fire] that his substance use involved the use of more
`drugs and was more regular than previously reported.” App. vol. 3, at 96. When
`admitted to Catalyst, A.C. reported that he first used alcohol at age twelve.
`6
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`mechanism for his mental-health struggles and stated that “[i]n spite of
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`resolutions to change, [A.C.] is likely to act out again in the future.” Id. at 102–
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`03. Dr. Chiles diagnosed A.C. with “moderate to severe” cannabis use disorder
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`and “moderate to severe” alcohol use disorder. Id. at 106. Because of that
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`diagnosis, he “strongly recommended” that A.C. continue treatment at an
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`inpatient residential facility with access to substance-use treatment. A.C. was
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`discharged from Blue Fire on June 23, 2016.
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`The next day, A.C. was admitted to Catalyst. Catalyst’s treatment plan
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`listed five diagnoses as reasons for A.C.’s admission: (1) “Generalized anxiety
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`disorder,” (2) “Unspecified depressive disorder,” (3) “Cannabis use disorder,”
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`(4) “Parent-child relational problems,” and (5) “Alcohol use disorder.” App.
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`vol. 4, at 43. Though A.C. had been drug- and alcohol-free for eleven weeks
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`when he arrived at Catalyst, due to his preceding stay at Blue Fire, Catalyst
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`classified his cannabis use disorder and alcohol use disorder as “severe.” Id. As
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`a general requirement for A.C.’s treatment, Catalyst’s plan stated that A.C.
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`needed “a place where he can have a sustained amount of time in sobriety as his
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`drug use was severe and daily.” Id. The plan then laid out specific treatment
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`goals related to A.C.’s cannabis use disorder. One goal was for A.C. to
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`“demonstrate a clear understanding of the dynamics of substance dependence as
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`they relate personally to [him].” Id. at 47. Another goal was for A.C. “to
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`routinely identify situations and other factors that could pose a risk to [his]
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`sobriety.” Id.
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`To fulfill these treatment goals, Catalyst prescribed A.C. individual and
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`group therapy, on top of providing him an environment away from drugs and
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`alcohol. Catalyst’s medical records show that A.C. completed this therapy, as
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`directed by the treatment plan. During his treatment at Catalyst, A.C.
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`experienced substance cravings and reported having “flashbacks of drinking.”
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`App. vol. 6, at 46.
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`C. United’s Coverage
`
`On June 24, 2016, the date of A.C.’s admission to Catalyst, Ian C.
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`submitted a request for coverage to United. In response, United completed an
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`“Initial Facility-Based Review,” to determine A.C.’s eligibility for benefits.
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`App. vol. 7, at 189. United’s intake form states that, though substance abuse
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`was not a “primary driver” for A.C.’s admission to Catalyst, the “precipitant”
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`for his admission was a “risk for relapse on drugs and alcohol” and
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`“[i]nadequate relapse prevention strategies.” Id. at 192, 193. And the form
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`specifies that A.C. was admitted to treat his use of alcohol, Xanax, cannabis,
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`and cocaine. Id. at 194. The intake lists “Generalized anxiety d/o” as A.C.’s
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`primary diagnosis, and lists “Persistent depressive d/o,” “Oppositional defiant
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`d/o,” “Alcohol use d/o,” “Cannabis use d/o,” and “Attention-
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`deficient/hyperactivity” as additional diagnoses. Id. at 191. Noting these
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`collective diagnoses and applying the Mental Health Guidelines, United
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`approved benefits for A.C. to receive four days of residential treatment at
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`Catalyst.
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`After the initial four days elapsed, United revisited A.C.’s eligibility.
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`Upon review, United approved A.C. for four additional days at Catalyst
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`because his symptoms were “not manageable in a less restrictive setting.” Id.
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`at 203–04. United documented A.C.’s mental state as “anxious, restless,
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`irritable, depressed,” and “sad,” and added that A.C. was “having high cravings
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`for using.” Id. at 204. Four days later, United conducted another review and
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`authorized another three days of coverage. This time, United reported that A.C.
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`was experiencing “craving for substances,” feeling “anxious,” “depressed,”
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`“isolat[ed],” and suffering visual hallucinations.4 Id. at 213. Three days later,
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`United reassessed A.C.’s condition and his eligibility yet again. United found
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`that A.C. was “restless,” “telling therapist[s] what they want[ed] to hear,” and
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`“professing sobriety despite [his] long [history] of drug use,” which led United
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`to conclude that A.C.’s symptoms, once again, could not be treated in a “less
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`restrictive setting.” Id. at 219, 221.
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`This litany of short-lived extensions brings us to July 7, 2016. By that
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`time, A.C. had received two weeks of treatment at Catalyst, which United
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`covered. Then, Ian C. requested United to cover another thirty days. This time,
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`4 United’s internal notes for this extension show that the reviewer used
`the “LOC SA Residential rehabilitation” guidelines to evaluate A.C.’s
`eligibility for benefits. App. vol. 7, at 214. This notation indicates that the
`reviewer used the “level of care” guidelines for “substance abuse” to assess
`coverage, which differs from all the other reviews that used the “LOC MH
`Residential treatment” guidelines, or rather, the Mental Health Guidelines. E.g.,
`id. at 28, 197, 205, 222. United’s one-time use of the Substance Abuse
`Guidelines is not mentioned by either party, so we will not discuss it further.
`9
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`United declined the request. In fact, United not only rejected Ian C.’s request
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`for a thirty-day extension, but it also denied coverage for A.C.’s residential
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`treatment moving forward and recommended that he be discharged to intensive
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`outpatient therapy. United based this decision on the Mental Health Guidelines,
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`determining that “the treatment being recommended” for A.C.’s general anxiety
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`disorder did “not appear to be consistent with generally accepted standards of
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`medical practice.” Id. at 233. United’s internal-review notes accompanying its
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`recommendation show that A.C. was still reporting cravings and had
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`experienced a “flash back of drinking” two days earlier that “triggered him.”
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`Id. at 230.
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`D.
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`Level One Denial
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`United sent its decision to deny coverage to a peer reviewer, Dr. Sheryl
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`Jones, to corroborate or challenge its determination. To assess the claim, Dr.
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`Jones reviewed United’s internal notes on A.C.’s case, called “Linx Case
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`Notes,” and interviewed a designee from Catalyst. Using this information and
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`applying the Mental Health Guidelines, Dr. Jones affirmed United’s adverse
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`benefit determination. She found that A.C.’s continued treatment at Catalyst
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`was not covered by the plan because his treatment no longer met the “Medical
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`Necessity Criteria.” Id. at 238–39. This decision became effective July 8, 2016.
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`Dr. Jones sent a letter to Ian C. notifying him that A.C.’s benefits from
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`July 8, 2016 forward had been denied. See 29 U.S.C. § 1133(1). This letter,
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`dated July 12, 2016, provides that “[a]fter speaking with the facility designee,
`10
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`it seems that your child has made progress and that his condition no longer
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`meets guidelines for coverage of treatment in this setting.” App. vol. 3, at 23.
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`Though Dr. Jones acknowledged that A.C. was admitted partially for “treatment
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`of substance use,” she expounded that A.C. did “not have serious withdrawal or
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`post-acute withdrawal symptoms” that would justify continued coverage. Id.
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`E.
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`Level Two Denial
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`After receiving Dr. Jones’s letter, Ian C. invoked his right to appeal
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`under the plan. He authored a “Level One Member Appeal,” dated January 4,
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`2017, challenging Dr. Jones’s decision on several grounds. Id. at 4–17. Most
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`saliently, he argued that Dr. Jones neglected to apply the Substance Abuse
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`Guidelines along with the Mental Health Guidelines. He also accused Dr.
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`Jones’s letter of violating ERISA regulations, which require plan administrators
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`to furnish “specific references in the medical records relied upon in reaching
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`their conclusion.” Id. at 7, 8.
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`Ian C.’s appeal stressed the severity of A.C.’s substance abuse and
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`attested that outpatient therapy had been powerless to treat A.C.’s addictions in
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`the past. He urged the next reviewer to reassess A.C.’s claim under the
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`Substance Abuse Guidelines, which supported his position that A.C. was not
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`ready to be discharged from an inpatient facility. Ian C. provided the next
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`reviewer with several documents to consider with his appeal. He included in the
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`body of his appeal an excerpted reference letter from Dr. Peacock, A.C.’s child
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`psychologist, and excerpted medical records from Catalyst. Attached to the
`11
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`appeal letter, Ian C. appended A.C.’s medical records from Blue Fire, a
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`medication disclosure form, Dr. Chiles’s evaluation, and more medical records
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`from Catalyst.
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`United assigned Dr. Cheryl Person to conduct the second review of
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`Ian C.’s claim. According to the plan, Dr. Person was a licensed psychiatrist
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`who was uninvolved in the initial adverse benefit determination. After
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`reviewing Ian C.’s “appeal letter, case notes, medical records and [the Mental
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`Health Guidelines],” Dr. Person upheld Dr. Jones’s denial of benefits. App.
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`vol. 7, at 42.
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`Dr. Person officially communicated her decision to Ian C. in a denial
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`letter dated January 19, 2017.5 The letter explained that because A.C. “had
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`made progress,” “was not endangering the welfare of himself or others,” “was
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`attending and participating in programming,” and “was tapered off his
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`antidepressants as his mood was stable,” he no longer met the criteria for
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`coverage under the Mental Health Guidelines. Id. at 42–43. Dr. Person noted
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`that A.C. was admitted to Catalyst for “General Anxiety Disorder,” without
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`mentioning his substance-abuse-related diagnoses. Id. at 42. She identified
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`A.C.’s “remaining symptoms,” as “parental-child conflict,” which she deduced
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`could be treated “in a less restrictive setting.” Id. at 43.
`
`
`5 A.C.’s provider notified United that it did not receive Dr. Person’s
`letter, and so United issued a second copy dated March 31, 2017. There is no
`substantive difference between the two versions.
`12
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`Upon receiving Dr. Person’s letter, Ian C. had exhausted the internal
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`appeals process available to him under the plan. And so, he invoked his right to
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`sue United in federal district court. See 29 U.S.C. § 1132(a)(1)(B).6
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`II.
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`Procedural Background
`
`On July 5, 2019, Ian C. filed a complaint against United seeking
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`(1) recovery of benefits under ERISA, 29 U.S.C. § 1132(a)(1)(B); and
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`(2) injunctive relief. He voluntarily dismissed the second claim with prejudice
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`in a stipulated motion. Ian C. and United then filed motions for summary
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`judgment on the ERISA claim. On August 11, 2022, the district court granted
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`summary judgment for United and entered judgment the same day. This timely
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`appeal followed.
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`III. Standard of Review
`
`A.
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`Summary Judgment
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`“Where, as here, the parties in an ERISA case both moved for summary
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`judgment, summary judgment is merely a vehicle for deciding the case; the
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`factual determination of eligibility for benefits is decided solely on the
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`administrative record, and the nonmoving party is not entitled to the usual
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`inferences in its favor.” Carlile v. Reliance Standard Life Ins. Co., 988 F.3d
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`1217, 1221 (10th Cir. 2021) (cleaned up).
`
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`6 Section 1132(a)(1)(B) empowers a plan participant to bring a civil
`action against the plan administrator “to recover benefits due to him under the
`terms of his plan” or “to enforce his rights under the terms of the plan.”
`13
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`Because the parties dispute the proper standard of review, we address
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`that issue first.
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`B.
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`ERISA Review Standards
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`Typically, we review motions for summary judgment de novo. Nat’l
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`Union Fire Ins. Co. of Pittsburgh v. Dish Network, LLC, 17 F.4th 22, 29
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`(10th Cir. 2021). But ERISA cases are a horse of a different color. In the
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`ERISA context, we proceed de novo unless the plan authorizes the
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`administrator to determine benefits on a discretionary basis, in which case we
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`apply the more deferential arbitrary-and-capricious review standard. See
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`Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989) (establishing
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`the standard of review for § 1132(a)(1)(B) appeals).
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`Ian C.’s plan grants United authority to interpret the terms of the plan
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`and make discretionary benefits decisions. This would suggest arbitrary-and-
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`capricious review. See Eugene S. v. Horizon Blue Cross Blue Shield of N.J.,
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`663 F.3d 1124, 1131 (10th Cir. 2011); Firestone, 489 U.S. at 115. But Ian C.
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`argues that we should review his appeal de novo because United failed to
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`“substantially comply” with ERISA’s procedural requirements.7 See Hancock v.
`
`
`7 The substantial-compliance rule was born out of a desire to avoid a
`“hair-trigger” rule that would divest plan administrators of their deference to
`make benefits decisions for trivial infractions of ERISA’s requirements. See
`LaAsmar v. Phelps Dodge Corp. Life, Accidental Death & Dismemberment &
`Dependent Life Ins. Plan, 605 F.3d 789, 799 (10th Cir. 2010); Finley v.
`Hewlett-Packard Co. Emp. Benefits Org. Income Protection Plan, 379 F.3d
`1168, 1173–74 (10th Cir. 2004). Instead, we withhold judicial deference only
`(footnote continued)
`
`
`
`14
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`Appellate Case: 22-4082 Document: 010110963219 Date Filed: 12/05/2023 Page: 15
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`Metro. Life Ins. Co., 590 F.3d 1141, 1152 (10th Cir. 2009) (“[D]e novo review
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`may be appropriate if the benefit-determination process did not substantially
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`comply with ERISA regulations . . . .”). And more broadly, owing to the
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`Department of Labor’s 2002 and 2011 amendments to the ERISA regulations,
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`Ian C. proposes that we adopt de novo review for all cases in which
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`administrators fail to “strictly adhere[]” to ERISA regulations. Op. Br. at 15,
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`16, 17, 19 (first quoting 29 C.F.R. § 2560.503-1(a) (“2002 regulations”); and
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`then quoting 29 C.F.R. § 2590.715-2719(b)(2)(ii)(F)(1)-(2) (“2011
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`regulations”)). United and the United States Chamber of Commerce, amicus
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`curiae, argue that the default arbitrary-and-capricious review standard should
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`remain. We agree.
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`The Supreme Court created the default deferential-review standard for
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`ERISA claims in Firestone, 489 U.S. at 115. The Court reasoned that judicial
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`deference to decisions issued by plan administrators was appropriate because
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`“ERISA abounds with the language and terminology of trust law,” which
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`traditionally accords deference to the discretionary exercise of fiduciary duties.
`
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`when administrators fail to show a “valid exercise” of their discretion.
`Gilbertson v. Allied Signal, Inc., 328 F.3d 625, 631 (10th Cir. 2003)
`(addressing the case when “the administrator’s ‘deemed denied’ decision is by
`operation of law rather than the exercise of discretion”). Otherwise,
`administrators are considered in “substantial compliance” with ERISA, and
`thus deserving of judicial deference. See id. at 636 (explaining that substantial
`compliance requires the administrator to be engaged in “an ongoing productive
`evidence-gathering process in which the claimant is kept reasonably well-
`informed”).
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`Id. at 110–11. The Court has faced multiple opportunities to overturn or
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`otherwise tweak Firestone deference; and in every instance, it has declined.
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`See, e.g., Conkright v. Frommert, 559 U.S. 506, 517 (2010) (reaffirming the
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`role Firestone deference plays in preserving ERISA’s “careful balancing”
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`between beneficiaries’ rights and administrators’ interests (quoting Aetna
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`Health Inc. v. Davila, 542 U.S. 200, 215 (2004))); Metro Life Ins. Co. v. Glenn,
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`554 U.S. 105, 115 (2008) (reexamining and upholding Firestone deference even
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`when the administrator had a conflict of interest). In fact, in Glenn, the Court
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`expressly repudiated the prospect of “near universal review by judges de novo
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`. . . of the lion’s share of ERISA plan claims denials.” 554 U.S. at 116.
`
`Nothing in Ian C.’s brief convinces us to stir the pot.8 First and foremost,
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`his argument assumes that the Department of Labor’s ERISA regulations can,
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`or should, dictate our judicial standards of review. That is a flawed premise.
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`Congress delegated authority to the Secretary of Labor to enact procedural
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`regulations to enforce ERISA’s policies, but that authorizing legislation never
`
`
`8 In Kellogg v. Metropolitan Life Insurance Co., we addressed a similar
`argument about the 2002 regulations’ impact on the substantial-compliance
`rule. 549 F.3d 818, 828 (10th Cir. 2008) (entertaining the idea that the 2002
`ERISA regulations “called into question the continuing validity of the
`substantial compliance rule”). But there, we declined to decide the issue
`because the administrator’s violation of ERISA deadlines was so egregious and
`blatant that there was “little doubt” the administrator had failed to comply with
`ERISA’s requirements, substantially or otherwise. See id.; see also Rasenack ex
`rel. Tribolet v. AIG Life Ins. Co., 585 F.3d 1311, 1316–17 (10th Cir. 2009)
`(declining to extend deference because AIG supplied no “good faith”
`justification for its repeated violations of ERISA-mandated deadlines).
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`Appellate Case: 22-4082 Document: 010110963219 Date Filed: 12/05/2023 Page: 17
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`mentioned judicial standards of review. See 29 U.S.C. § 1135 (authorizing the
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`Secretary to “prescribe such regulations as he finds necessary or appropriate to
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`carry out the provisions of this subchapter”). Congress intentionally left
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`ERISA’s standard of review open to the judiciary’s interpretation, which the
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`Supreme Court duly supplied in Firestone. See Glenn, 554 U.S. at 116
`
`(perceiving that Congress “left to the courts the development of review
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`standards” for ERISA actions).
`
`Second and more practically, because United cannot surmount arbitrary-
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`and-capricious review, it would be fruitless for us to proceed de novo. See, e.g.,
`
`David P. v. United Healthcare Ins. Co., 77 F.4th 1293, 1308 n.11 (10th Cir.
`
`2023) (dispensing with de novo review even when it was appropriate because
`
`“[United’s] adverse benefits determination fail[ed] . . . an arbitrary and
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`capricious standard of review”). Thus, this case is not an appropriate vehicle
`
`for us to reevaluate our standard of review.
`
`C. Arbitrary-and-Capricious Review
`
`Our review goes to the plan administrator’s decision, not the district
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`court’s. See Foster v. PPG Indus., Inc., 693 F.3d 1226, 1231 (10th Cir. 2012)
`
`(quoting Holcomb v. Unum Life Ins. Co. of Am., 578 F.3d 1187, 1192 (10th Cir.
`
`2009)). We review the plan administrator’s decision for arbitrariness and
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`capriciousness. Id.
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`“Under arbitrary and capricious review, this court upholds [the
`
`administrator’s] determination so long as it was made on a reasoned basis and
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`Appellate Case: 22-4082 Document: 010110963219 Date Filed: 12/05/2023 Page: 18
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`supported by substantial evidence.” Van Steen v. Life Ins. Co. of N. Am.,
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`878 F.3d 994, 997 (10th Cir. 2018); see Foster, 693 F.3d at 1231–32 (clarifying
`
`that, in the ERISA context, we treat “the abuse-of-discretion standard and the
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`arbitrary-and-capricious standard as interchangeable” (cleaned up)).
`
`“Substantial evidence is such evidence that a reasonable mind might accept as
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`adequate to support the conclusion reached by the decisionmaker.” Sandoval v.
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`Aetna Life and Cas. Ins. Co., 967 F.2d 377, 382 (10th Cir. 1992) (cleaned up).
`
`And as we consider “whether the evidence in support of the administrator’s
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`decision is substantial, we must take into account whatever in the record fairly
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`detracts from its weight.” Graham v. Hartford Life & Accident Ins. Co., 589
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`F.3d 1345, 1358 (10th Cir. 2009) (quoting Caldwell v. Life Ins. Co. of N. Am.,
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`287 F.3d 1276, 1282 (10th Cir. 2002)).
`
`When issuing an adverse benefit determination, an administrator must
`
`provide the participant “adequate notice in writing . . . setting forth the specific
`
`reasons for such denial, written in a manner calculated to be understood by the
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`participant.” 29 U.S.C. § 1133(1). After the administrator issues an adverse
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`benefit determination, the participant is entitled to a “reasonable opportunity”
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`for a “full and fair review” of the decision. Id. § 1133(2). A “full and fair
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`review” discloses to the participant the “evidence the decision-maker relied
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`upon.” D.K. v. United Behav. Health, 67 F.4th 1224, 1236 (10th Cir. 2023)
`
`(quoting Sage v. Automation, Inc. Pension Plan & Tr., 845 F.2d 885, 893–94
`
`(10th Cir. 1988)). Our review is limited to “those rationales that were
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`specifically articulated in the administrative record as the basis for denying a
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`claim.” Spradley v. Owens-Illinois Hourly Empls. Welfare Benefit Plan,
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`686 F.3d 1135, 1140 (10th Cir. 2012) (quoting Flinders v. Workforce
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`Stabilization Plan of Phillips Petroleum Co., 491 F.3d 1180, 1190 (10th Cir.
`
`2007), overruled on other grounds by Glenn, 554 U.S. at 128, as recognized in
`
`Holcomb, 578 F.3d at 1192–93).
`
`Recently, in D.K. v. United Behavioral Health, we held that the
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`administrator must include its reasons for denying coverage in the four corners
`
`of the denial letter. 67 F.4th at 1239 (“ERISA denial letters play a particular
`
`role in ensuring full and fair review. ERISA regulations require that denial
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`letters be comprehensive and include . . . specific reasons for the denial.”
`
`(citing 29 C.F.R. § 2560.503-1(f)(3), (h)(3)–(4))). Under D.K., our analysis
`
`focuses on the two denial letters United furnished to Ian C., the first from Dr.
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`Jones communicating the initial denial decision, but more critically the second
`
`from Dr. Person affirming the denial on appeal.9
`
`
`
`
`
`
`9 D.K. established that our review of an administrator’s benefits denial is
`confined to the denial letters. See 67 F.4th at 1239. Though United sent two
`denial letters, Dr. Person’s letter pulls focus because Ian C. appeals based on an
`independent-ground-for-coverage theory. After Ian C. received the initial denial
`from Dr. Jones, he specifically raised substance abuse as an independent ground
`for coverage for the next reviewer to consider. As the second