ERISA Procedural Arbitrary-and-Capricious Review: Administrators Must Grapple with Treating-Clinician Evidence and Rationally Explain Benefit Reversals; Parity Act As-Aplied Claims Require Comparator Evidence

Introduction

In T. E. v. Anthem Blue Cross Blue Shield (6th Cir. Jan. 22, 2026), the Sixth Circuit reviewed an insurer-administrator’s denial of continued coverage for a minor’s long-term residential mental-health treatment. The plaintiff, T.E., enrolled his son C.E. at Elevations, a residential-treatment center, after years of unsuccessful outpatient and short-term higher-acuity interventions. Anthem, administering the governing plan, initially authorized and paid for 21 days of residential treatment but then denied any further days as not “medically necessary” under the plan’s referenced criteria (the MCG Guideline for Residential Behavioral Health Level of Care, Child or Adolescent).

The litigation presented two core issues:

  • ERISA: Whether Anthem’s coverage denial was arbitrary and capricious under ERISA’s judicial review framework where the plan granted Anthem discretionary authority.
  • Mental Health Parity and Addiction Equity Act (Parity Act): Whether Anthem applied more restrictive (or separate) “treatment limitations” to mental-health benefits than to medical/surgical benefits.

The court held Anthem’s denial was procedurally arbitrary and capricious under ERISA and required remand for a “full and fair review,” but affirmed summary judgment for Anthem on the Parity Act claim because T.E. failed to identify record evidence enabling the statute’s required medical/surgical comparator analysis.

Summary of the Opinion

  • ERISA claim: The Sixth Circuit vacated summary judgment for Anthem. It held Anthem’s denial was procedurally arbitrary and capricious because Anthem (i) ignored treating-clinician opinions, (ii) cherry-picked the record, and (iii) failed to adequately explain its reversal after initially approving coverage—especially by relying on a “risk of harm” rationale that did not match either its initial approval rationale or the governing MCG discharge criteria.
  • Remedy: The court ordered remand to the plan administrator (via the district court) rather than awarding benefits, because the errors were process errors and the claimant was not “clearly entitled” to benefits on the existing record.
  • Parity Act claim: The court affirmed summary judgment for Anthem. Even assuming a private right of action existed (a question the court noted it had not resolved), T.E. offered only “bare allegations” and did not identify evidence of Anthem’s medical/surgical treatment limitations and their application in practice—making the required statutory comparison impossible.

Analysis

Precedents Cited

1) ERISA standard of review and the procedural/substantive framework

  • Autran v. Proctor & Gamble Health & Long-Term Disability Benefit Plan, 27 F.4th 405 (6th Cir. 2022): Cited for applying arbitrary-and-capricious review when the administrator has discretionary authority and for the requirement of “reasoned decisionmaking.” The court used Autran to frame why ignoring treating evidence and relying on file reviews can signal procedural unreasonableness.
  • Goodwin v. Unum Life Ins. Co. of Am., 137 F.4th 582 (6th Cir. 2025): Provided the key structure that arbitrary-and-capricious review has procedural and substantive components and listed non-dispositive procedural factors (considering all relevant evidence; explaining changes from earlier rulings; privileging file reviewers over in-person assessors). The court relied heavily on Goodwin—especially the obligation to rationally explain a “yes” to “no” reversal.
  • Davis v. Hartford Life & Accident Ins. Co., 980 F.3d 541 (6th Cir. 2020): Cited for the definition of “substantial evidence.” Notably, the court did not reach the substantive “substantial evidence” question because the procedural failures were dispositive.

2) Treating-clinician evidence, file reviews, and selective record review

  • Elliot v. Metro. Life Ins. Co., 473 F.3d 613 (6th Cir. 2006): Central to the court’s holding that administrators may not “reject summarily” treating opinions and must “give reasons” for deviating. The court also borrowed Elliot’s logic that a naked claim of “improvement” without baselines is not a meaningful medical-necessity explanation.
  • Glenn v. MetLife, 461 F.3d 660 (6th Cir. 2006): Used for the proposition that failure to indicate consideration of treating opinions supports finding arbitrariness.
  • Butler v. United Healthcare of Tenn., Inc., 764 F.3d 563 (6th Cir. 2014): Cited where reviewers “never explained” disagreement with treating clinicians and where ignoring “key pieces of evidence” undermines full and fair review.
  • Okuno v. Reliance Standard Life Ins. Co., 836 F.3d 600 (6th Cir. 2016): Reinforced skepticism when administrators rely on “mere ‘file’ review,” particularly in claims involving a “mental illness component.”
  • DeLisle v. Sun Life Assurance Co. of Can., 558 F.3d 440 (6th Cir. 2009): Supported the court’s rejection of Anthem’s argument that merely “citing” a clinician’s report suffices; administrators must address the relevant aspects “head on.”
  • Kalish v. Liberty Mutual/Liberty Life Assurance Co. of Bos., 419 F.3d 501 (6th Cir. 2005): Cited to show an administrator can ignore evidence without making express contradictions.
  • Metro. Life Ins. Co. v. Conger, 474 F.3d 258 (6th Cir. 2007): Cited for the proposition that “cherry-picking” is a hallmark of arbitrary-and-capricious review.
  • Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003): Used for the broader principle that an administrator may not “arbitrarily refuse to credit a claimant’s reliable evidence.”

3) Notice, scope-of-review debate, and reason-giving

  • Statute: 29 U.S.C. § 1133(1) (adequate notice; “specific reasons” for denial). The court discussed—but did not decide—whether judicial review should be limited to reasons disclosed to the claimant in denial letters.
  • D.K. v. United Behavioral Health, 67 F.4th 1224 (10th Cir. 2023), and Glista v. Unum Life Ins. Co. of Am., 378 F.3d 113 (1st Cir. 2004): Cited as examples of circuits that limit arbitrary-and-capricious review to the reasons provided in denial letters. The Sixth Circuit expressly left this question open, finding Anthem’s denial arbitrary even considering undisclosed internal materials.
  • Love v. National City Corp. Welfare Benefits Plan, 574 F.3d 392 (7th Cir. 2009): Quoted for the proposition that “bare conclusions are not” an “explanation,” underscoring the Sixth Circuit’s insistence on reasoned articulation rather than conclusory denials.

4) Remedy: remand vs. award of benefits

  • Shaw v. AT & T Umbrella Benefit Plan No. 1, 795 F.3d 538 (6th Cir. 2015): Stated the remedial fork: award benefits or remand to administrator.
  • Card v. Principal Life Ins. Co., 17 F.4th 620 (6th Cir. 2021) (per curiam): Explained that process errors typically justify remand because they do not necessarily establish entitlement.
  • Elliot v. Metro. Life Ins. Co., 473 F.3d 613 (6th Cir. 2006): Reinforced that awarding benefits is appropriate only when the claimant is “clearly entitled,” and cautioned courts against substituting their judgment for medical specialists.

5) Parity Act: comparator evidence and summary judgment burdens

  • Statute: 29 U.S.C. § 1185a(a)(3)(A) and 29 U.S.C. § 1185a(a)(3)(B)(iii) (treatment limitations; “no more restrictive than” and “no separate” limitations; examples include “days of coverage” and similar limits on scope/duration).
  • E.W. v. Health Net Life Ins. Co., 86 F.4th 1265 (10th Cir. 2023): Cited for the unresolved question whether there is a private cause of action to enforce the Parity Act; the Sixth Circuit assumed arguendo and rejected on evidentiary grounds.
  • Cahoo v. SAS Inst., Inc., 71 F.4th 401 (6th Cir. 2023), and Mitchell v. Toledo Hosp., 964 F.2d 577 (6th Cir. 1992): Cited to emphasize that at summary judgment a plaintiff must identify evidence for each claim; bare allegations are insufficient.
  • Murthy v. Missouri, 603 U.S. 43 (2024): Cited for the principle that courts are not required to search for evidence “buried in the record” without adequate citation.
  • Celotex Corp. v. Catrett, 477 U.S. 317 (1986): Cited for the rule that failure to make a showing on essential elements warrants summary judgment.

Legal Reasoning

1) Procedural arbitrariness as an independent basis for vacatur

The court emphasized that ERISA arbitrary-and-capricious review includes a procedural inquiry: whether the administrator “engaged in reasoned decisionmaking.” Applying Goodwin v. Unum Life Ins. Co. of Am., the panel found three procedural defects sufficient to vacate without reaching whether Anthem’s decision was substantively supported by substantial evidence.

2) Failure to confront treating-clinician opinions

T.E. submitted multiple clinician opinions recommending continued residential treatment. Anthem’s denial letters did not address those opinions, and its reviewers did not explain disagreement. Under Elliot v. Metro. Life Ins. Co. and Glenn v. MetLife, administrators must provide reasons for rejecting treating opinions; they cannot simply adopt contrary file reviewers without explanation. The court found Anthem’s attempt to salvage this defect by pointing to incidental “citations” (especially Dr. Fisher’s partial reference to Dr. Manley) insufficient under DeLisle v. Sun Life Assurance Co. of Can., because Anthem never addressed the key recommendation: continued treatment at Elevations.

3) Cherry-picking and factual distortion

The court found Anthem selectively relied on snippets (e.g., “cooperative” intake descriptions) while ignoring later notes describing persistent dysregulation and conflict. The court also pointed to an instance where Anthem’s reviewer characterized milieu notes as showing C.E. “does well,” when the underlying note described struggle and only suggested 1:1 walks as a potential long-run intervention. Under Metro. Life Ins. Co. v. Conger and Black & Decker Disability Plan v. Nord, this kind of selective review undermines the claim of a full and fair evaluation.

4) Inadequate explanation for reversing an earlier approval (and misusing the guideline)

Anthem paid for 21 days, then stopped. Under Goodwin v. Unum Life Ins. Co. of Am., Anthem needed a rational explanation for changing its benefits answer from “yes” to “no.”

The court found Anthem’s stated rationale—essentially that C.E. was no longer “at risk for serious harm that needed 24 hour care”—failed for two related reasons:

  • It did not match Anthem’s own initial rationale for admission/coverage, which centered on “mood disorder” and “severe executive functioning” issues rather than imminent harm.
  • It did not match the MCG Guideline discharge criteria, which required meeting “all” criteria and did not make “risk of harm” dispositive for continued-stay necessity.

The initial denial letter’s additional statements (“improved,” “safe,” “medically stable,” “support,” “family session completed”) were criticized as conclusory and misaligned with the guideline’s actual continued-stay factors. The physician reports by Dr. Shah and Dr. Klaehn were condemned as unexplained bottom lines; quoting Love v. National City Corp. Welfare Benefits Plan, the court reiterated that bare conclusions are not explanations.

5) Remedy: remand for “full and fair inquiry”

The court treated Anthem’s failures as classic “process error” and applied the Sixth Circuit’s remedial approach from Shaw v. AT & T Umbrella Benefit Plan No. 1 and Card v. Principal Life Ins. Co.. Because the panel could not say T.E. was “clearly entitled” to benefits under Elliot v. Metro. Life Ins. Co., it ordered remand to Anthem for further assessment rather than awarding benefits outright.

6) Parity Act: the minimum evidentiary requirement is comparator proof

The court acknowledged that it had not previously interpreted or applied the Parity Act and noted the unresolved issue whether a private cause of action exists, citing E.W. v. Health Net Life Ins. Co.. But it held that, at minimum, the statute’s text requires a comparison: whether mental-health “treatment limitations” are “more restrictive” than, or “separate” from, those applied to medical/surgical benefits.

Because T.E. did not identify record evidence showing what Anthem’s medical/surgical treatment limitations were (or how they were applied in practice), he could not satisfy the statute’s comparative structure. Under Cahoo v. SAS Inst., Inc., Mitchell v. Toledo Hosp., Murthy v. Missouri, and Celotex Corp. v. Catrett, this evidentiary gap was fatal at summary judgment.

Impact

1) ERISA claims involving mental-health residential treatment

  • Stronger enforcement of procedural rigor: The decision underscores that ERISA procedural deficiencies—ignoring treating opinions, cherry-picking, and failing to explain reversals—can independently require vacatur and remand without reaching “substantial evidence.”
  • Guideline fidelity matters: When a plan incorporates or relies on a specific clinical guideline, the administrator’s stated reasons must map onto the guideline’s actual criteria (especially where the guideline requires multiple discharge factors rather than a single risk-of-harm narrative).
  • File review skepticism (especially for mental illness): Consistent with Okuno v. Reliance Standard Life Ins. Co., heavy reliance on file reviewers becomes more vulnerable when the administrator fails to explain why their view overrides treating clinicians who observed the patient directly.
  • Unresolved Sixth Circuit question on “scope of review”: By declining to decide whether review is limited to denial letters (as in D.K. v. United Behavioral Health and Glista v. Unum Life Ins. Co. of Am.), the court leaves a live issue for future ERISA litigation—particularly where internal rationales are undisclosed during the administrative process.

2) Parity Act litigation strategy in the Sixth Circuit

  • Comparator evidence is indispensable: An as-applied Parity Act claim must be built around evidence of medical/surgical treatment limitations and their real-world application, not only criticism of the mental-health determination.
  • Record development is outcome-determinative: The decision effectively warns plaintiffs that parity theories must be supported by a record containing medical/surgical analogs (guidelines, authorization criteria, application examples, or other proof) and clear citations—otherwise summary judgment is likely.
  • Private right of action remains uncertain: The panel avoided deciding whether the Parity Act is privately enforceable in the Sixth Circuit, preserving future threshold litigation on that point.

Complex Concepts Simplified

  • “Arbitrary and capricious” (ERISA): A deferential standard of review, but not a rubber stamp. The administrator must show a rational, reasoned process and a decision grounded in the record.
  • Procedural vs. substantive review: Procedural review asks whether the insurer followed a fair and reasoned process (considered evidence, explained changes, avoided cherry-picking). Substantive review asks whether the result is supported by “substantial evidence.”
  • “Treating clinician” vs. “file reviewer”: Treating clinicians evaluate the patient in person; file reviewers assess paper records. ERISA does not impose a strict treating-physician rule, but administrators must still explain why they reject treating opinions.
  • “Cherry-picking”: Selecting only favorable snippets of the record while ignoring contrary parts—especially when the ignored parts bear directly on the governing criteria.
  • Remand vs. award of benefits: If the problem is the process (insufficient reasoning), courts often remand to the administrator to redo the decision properly. Benefits are awarded only when entitlement is clear.
  • Parity Act “treatment limitations” and “comparison”: The statute is comparative: the plaintiff must show mental-health limits are more restrictive than medical/surgical limits. That requires proof of both sides of the comparison.

Conclusion

T. E. v. Anthem Blue Cross Blue Shield reinforces that ERISA’s deferential standard still demands disciplined process: administrators must meaningfully address treating-clinician evidence, avoid selective record use, and provide a rational explanation—especially when reversing an initial coverage approval and when a cited guideline requires more than a single-factor rationale. The court’s remedial choice—remand rather than benefits—signals that procedural violations typically warrant a do-over, not judicial substitution of medical judgment.

On parity, the decision sets a practical (and text-driven) evidentiary floor: an as-applied Parity Act claim cannot proceed without record evidence of medical/surgical treatment limitations and how they are applied, enabling the statutory comparison. In short, this opinion simultaneously raises the bar for ERISA reason-giving in residential mental-health denials and clarifies that parity claims live or die on comparator proof.