After suffering a heart attack, the plaintiff was placed in a nursing home. Initially, Blue Cross agreed to pay the costs, but then later changed its mind. The plaintiff’s claim for continued benefits turned on whether his care at a nursing home qualifies as Skilled Nursing Care, which is covered, or Custodial Care, which is not. Addressing the plaintiff’s Substantial Compliance argument, the Fifth Circuit noted that “ERISA regulations provide insight into what constitutes full and fair review. Applicable regulations dictate that procedures ‘will not be deemed to provide a claimant with a reasonable opportunity for a full and fair review of a claim and adverse benefit determination’ unless several procedural requirements are met, four of which are relevant to this appeal: (1) review must ‘not afford deference to the initial adverse benefit determination’ and may not be ‘conducted’ by the same person who made the initial determination; (2) when an ‘adverse benefit determination … is based in whole or in part on a medical judgment,’ the appeal must include consultation ‘with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment’; (3) the claims procedure must ‘provide for the identification of medical or vocational experts whose advice was obtained on behalf of the plan in connection with a claimant’s adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination; and (4) the healthcare professional consulted in an appeal may not be the same individual who was consulted in connection with the original determination. We find that Blue Cross did not substantially comply with the procedural requirements of ERISA because (1) it raised new grounds for denial in the federal courts that were not raised at the administrative level; (2) it did not identify the board certified urologist, despite Lafleur’s request for this information; (3) it relied on the same urologist’s opinion in the initial denial and in the administrative appeals; (4) to the extent it did not rely on the urologist’s opinion in the administrative appeals, it relied on Dr. Brower’s opinion even though he did not possess appropriate training and experience in the field of urology; and (5) it effectively gave deference to the initial denial.” Declining to extend a substantive damages remedy, the Court remanded to the plan administrator for full and fair review. Lafluer v. La. Health Services and Indemnity, 563 F.3d 148 (5th Cir. 2009).