Opinion

Wahi v. Charleston Area Medical Center, Inc.

562 F.3d 599
29 I.E.R. Cas. (BNA) 32
2009 U.S. App. LEXIS 7672
2009 WL 962310

Court: Court of Appeals for the Fourth Circuit
Filed: Apr 10, 2009
Status: Published
Author: Agee
On the bench: Gregory, Agee, Smith, Eastern, Virginia
Cited by: 578 cases
Authority: More cited than 99.2%

holding pre-suspension hearing not necessary under the circumstances when: (1) suspension was instituted only shortly before doctor had opportunity to present case at committee meeting; (2) doctor had earlier been informed of investigation and provided opportunity to respond in writing; (3) "allegations were simply the latest in [the doctor’s] tumultuous history,” which included three prior suspensions; 'and (4) hospital diligently worked to arrange acceptable post-decision hearing but doctor “seemed more intent on forestalling a hearing than having one”

How later courts described this case

holding pre-suspension hearing not necessary under the circumstances when: (1) suspension was instituted only shortly before doctor had opportunity to present case at committee meeting; (2) doctor had earlier been informed of investigation and provided opportunity to respond in writing; (3) "allegations were simply the latest in [the doctor’s] tumultuous history,” which included three prior suspensions; 'and (4) hospital diligently worked to arrange acceptable post-decision hearing but doctor “seemed more intent on forestalling a hearing than having one”
explaining that a private entity’s activity is generally not actionable under § 1983 “unless the state has so dominated such activity as to convert it to state action”
explaining that a party’s single declarative sentence, without citations to authorities or the record, is insufficient to raise an argument on appeal
holding that a single declarative sentence, without citations to authorities or the record, is insufficient to raise an argument on appeal

Written by the judges who cited it.

The opinion

PUBLISHED

UNITED STATES COURT OF APPEALS

FOR THE FOURTH CIRCUIT

RAKESH WAHI, 

Plaintiff-Appellant,

CHARLESTON AREA MEDICAL

CENTER, INCORPORATED, a West

Virginia Corporation; GLENN

CROTTY; JOHN DOES I-X,

Defendants-Appellees,

and

 No. 06-2162

JANE DOES I-X; JAMAL KAHN; H.

RASHID; K. C. LEE; ANDREW

VAUGHN; JOHN L. CHAPMAN,

Defendants.

ASSOCIATION OF AMERICAN

PHYSICIANS AND SURGEONS,

INCORPORATED,

Amicus Supporting Appellant.



Appeal from the United States District Court

for the Southern District of West Virginia, at Charleston.

Joseph R. Goodwin, Chief District Judge.

(2:04-cv-00019)

Argued: December 2, 2008

Decided: April 10, 2009

2 WAHI v. CHARLESTON AREA MEDICAL CENTER

Before GREGORY and AGEE, Circuit Judges, and Rebecca

Beach SMITH, United States District Judge for the Eastern

District of Virginia, sitting by designation.

Affirmed by published opinion. Judge Agee wrote the opin-

ion, in which Judge Gregory and Judge Smith joined.

COUNSEL

ARGUED: Kenneth Winston Starr, PEPPERDINE UNIVER-

SITY SCHOOL OF LAW, Malibu, California, for Appellant.

Richard D. Jones, FLAHERTY, SENSABAUGH &

BONASSO, P.L.L.C., Charleston, West Virginia, for Appel-

lees. ON BRIEF: John C. Yoder, Harpers Ferry, West Vir-

ginia, for Appellant. David S. Givens, FLAHERTY,

SENSABAUGH & BONASSO, P.L.L.C., Wheeling, West

Virginia, for Appellees. Andrew L. Schlafly, Far Hills, New

Jersey, for Amicus Supporting Appellant.

OPINION

AGEE, Circuit Judge:

Rakesh Wahi, M.D., appeals the district court’s judgment

dismissing his numerous state and federal claims brought

against Charleston Area Medical Center, Inc. ("CAMC")

regarding the suspension of his medical privileges. The dis-

trict court concluded most of Wahi’s claims were barred

because CAMC qualified for immunity from suit under the

Health Care Quality Improvement Act ("HCQIA" or "the

Act"), 42 U.S.C.A. § 11101, et seq. (West 2005). For this rea-

son, and because the district court found Wahi’s other claims

failed on the merits, the court awarded CAMC and Dr. Glenn

WAHI v. CHARLESTON AREA MEDICAL CENTER 3

Crotty1 summary judgment. For the reasons set forth below,

we affirm the judgment of the district court.

CAMC is a privately-run hospital operating in Charleston,

West Virginia. Wahi, who is licensed to practice medicine in

West Virginia, began working as a cardio-thoracic surgeon at

CAMC in January 1993. (J.A. 98.) The following year, Wahi

started his own practice, but retained clinical privileges at

CAMC. Around the same time, he began discussions with a

Beckley, West Virginia medical group about the possibility of

associating with them. In November 1996, CAMC temporar-

ily suspended Wahi’s hospital privileges and, as required by

statute, it notified the National Practitioner’s Data Bank

("NPDB"),2 of Wahi’s suspension. CAMC later reinstated

Wahi’s clinical privileges on a provisional basis.3 (J.A. 49;

294; 511-16.) Following Wahi’s reinstatement, CAMC

received reports of and investigated several allegations that

Wahi violated the terms of his provisional clinical privileges,

which again resulted in temporary suspensions of Wahi’s

privileges in 1998 and 1999. From 1996 to 1999, CAMC, as

required by statute, reported Wahi to the NPDB a total of five

Dr. Crotty served as Executive Vice President and Chief Medical Offi-

cer at CAMC during the relevant period of Wahi’s employment; he is now

the Chief Operating Officer at CAMC. (J.A. 70, 117.)

The NPDB is a national clearinghouse designed to prevent incompetent

doctors from simply moving to a new state that could not discover their

prior poor performance. Under the HCQIA, hospitals are generally

required to report to the NPDB adverse professional review action "affec-

t[ing] the clinical privileges of a physician." See 42 U.S.C.A.

§ 11133(a)(1)(A) (West 2005).

Wahi’s status and privileges changed in subsequent periods, but at all

relevant times, he only possessed provisional privileges at CAMC and he

was subject to numerous restrictions, such as being required to get another

doctor’s approval before performing certain procedures and to have a

proctor present during other procedures. Wahi was also barred from per-

forming some procedures entirely. (J.A. 516-33, 655.)

4 WAHI v. CHARLESTON AREA MEDICAL CENTER

times, although the exact nature of each of the reports before

1999 is not in the record. These prior suspensions and investi-

gations are not at issue in this appeal.4 (J.A. 50, 517-71.)

At the time of the events in question, Wahi was exercising

provisional privileges at CAMC, and had requested reappoint-

ment for "an additional year ending February 26, 2000."5 (J.A.

532-33, 572.) In May 1999, the CAMC Credentials Committee6

("Credentials Committee") recommended that Wahi’s request

be granted, but that his privileges remain restricted "as cur-

rently in place with intensified review as outlined in the Medi-

cal Staff Procedures Manual."7 (J.A. 532.)

By letter dated July 8, 1999, the Credentials Committee

notified CAMC’s Chief of Staff, [REDACTED], that it was

rescinding its earlier recommendation to renew Wahi’s provi-

sional clinical privileges.8 This decision was made after

CAMC also filed several reports regarding Wahi’s professional con-

duct with the West Virginia Board of Medicine.

Under CAMC policy, an application for reappointment automatically

extends the current appointment period until the request is acted on. (J.A.

477; Procedures Manual 2.1.1.1.) Wahi’s application thus extended his

previous year’s appointment until final disposition of his application for

reappointment.

The Credentials Committee is composed of "one representative from

each of [CAMC’s] Medical Staff Departments" and two non-physician

non-voting members of the Board. It is charged with investigating the

"character, professional competence, qualifications and ethical standing

of" CAMC physicians who have "completed applications for appointment

or reappointment to the medical Staff," as well as requests for changes in

privileges. The Credentials Committee then makes a recommendation to

the Board on all such matters. (Bylaws 8.3.1, 8.3.2.1.) (J.A. 464.)

Three documents set forth the rights and responsibilities between

CAMC and its medical staff: the Medical Staff Procedures Manual

("Procedures Manual"), Medical Staff Bylaws ("Bylaws"), and Medical

Staff Rules & Regulations.

The district court incorrectly identified this letter as one addressed

directly to Wahi. There is no indication in the record that Wahi received

a copy of this letter or was made aware of the Credentials Committee’s

recommendation at that time.

WAHI v. CHARLESTON AREA MEDICAL CENTER 5

receiving information that Wahi performed a [REDACTED],

which he was not permitted to do under the terms of his provi-

sional clinical privileges. The Credentials Committee had also

been apprised that Wahi failed to notify CAMC, as required

by the by-laws, that he had voluntarily relinquished his clini-

cal privileges at another hospital. The Credentials Committee

requested "an investigation and appropriate suspension of Dr.

Wahi’s clinical privileges" in light of this new information of

Wahi’s continued failure to comply with the terms of his pro-

visional clinical privileges. The Credentials Committee

informed [REDACTED] that its recommendation had not

been communicated to the CAMC Board of Trustees, and that

Wahi would be given the opportunity to meet with them

"prior to any final recommendation." (J.A. 572-73.)

By letter dated July 16, 1999, [REDACTED] informed

Wahi that he had been requested to investigate the two claims

raised in the Credentials Committee’s letter. [REDACTED]

asked Wahi to "respond to each of the [allegations] in writing

as soon as possible." Attached to the letter were the relevant

portions of the Bylaws pertaining to the alleged violations.

(J.A. 115, 575-76.)

Between July 16 and July 30, in addition to meeting with

[REDACTED] to discuss the July 16 letter requesting addi-

tional information from Wahi, Wahi wrote to [REDACTED],

[REDACTED], and the Chairman of the Credentials Com-

mittee in order to provide an explanation of the events sur-

rounding the allegations against him. The Credentials

Committee scheduled a meeting with Wahi for August 3,

1999 to review his performance and consider his application,

which was later rescheduled for August 17, 1999, at Wahi’s

request. (J.A. 742.)

On July 30, 1999, [REDACTED] summarily suspended

Wahi’s hospital privileges at CAMC. (J.A. 50.) By letter on

the same date, CAMC formally notified Wahi that his "clini-

cal privileges [were] hereby summarily suspended pursuant to

6 WAHI v. CHARLESTON AREA MEDICAL CENTER

Section 2.4.1, Grounds for Summary Suspension of the Proce-

dures Manual, ‘for the best interest of patient care.’" (J.A.

117.) His suspension was to "continue until resolution of

[Wahi’s] request for reappointment and any appeal/hearing, if

requested, has been completed." (J.A. 117.) A copy of Article

III of the Procedures Manual was attached to the letter, and

Wahi was informed that he "may wish to avail [himself] of

any rights available to [him] under Article III." (J.A. 117,

586.)

From the time of his suspension through the Credentials

Committee meeting, Wahi engaged in ongoing correspon-

dence and discussions with CAMC regarding preparation for

that meeting and his application to renew clinical privileges.

(See, e.g., J.A. 118-30, 654.) On August 17, 1999, the Cre-

dentials Committee met and Wahi testified, providing his

response to the allegations against him. The Credentials Com-

mittee recommended denying Wahi’s application for reap-

pointment in a detailed August 26, 1999 letter. (J.A. 644-46.)

By a separate letter, also dated August 26, 1999, CAMC

informed Wahi of the denial of his request for reappointment

of his clinical privileges and of his right to a hearing regard-

ing this decision under Article III of the Procedures Manual.

(J.A. 644-47.)

On September 8, 1999, Wahi, by counsel, requested a hear-

ing regarding both his suspension and the decision not to

renew his clinical privileges. On September 13, 1999, CAMC

reported Wahi’s summary suspension to the NPDB, (J.A.

962.), and to the West Virginia Board of Medicine. (J.A. 701.)

Correspondence during the next several months indicates

on-going discussions between Wahi and CAMC regarding

Wahi’s access to his medical affairs/quality assurance file, his

dislike of the composition of the hearing panel, and other

aspects of the conduct of a hearing. CAMC repeatedly asked

Wahi to provide "a series of convenient dates . . . for the

scheduling of" the requested hearing. (J.A. 762-63, 776.)

WAHI v. CHARLESTON AREA MEDICAL CENTER 7

Wahi has never provided CAMC with any dates on which he

would be available for a hearing, and a hearing date was never

set. (J.A. 760.)

In November 2000, Wahi filed a complaint in West Vir-

ginia state court requesting that the court intervene in the

CAMC peer review process, declare certain of CAMC’s

actions invalid, require CAMC to withdraw its reports to the

NPDB and state Board of Medicine, and require a court-

administered hearing that satisfied Wahi’s various demands.

(J.A. 99-114.) The West Virginia court ultimately dismissed

the action on December 6, 2001, after concluding that Wahi

was not entitled to the relief he sought because the peer

review process was still ongoing. It declined to "render advi-

sory opinions" or accept Wahi’s "speculation" that he would

receive an unfair hearing. (J.A. 143, 131-46.)

For a while, discussions between Wahi and CAMC contin-

ued after the state court case ended, with both parties setting

forth various parameters and details of the conduct of a hear-

ing. Then discussions halted,9 with the parties never reaching

an agreement or conducting or scheduling a hearing. In Janu-

ary 2004, Wahi filed a complaint in the United States District

Court for the Southern District of West Virginia.

The complaint alleged numerous state and federal claims,

including Anti-Trust violations of the Sherman Act, against

CAMC and other defendants.10 (R. 3.) CAMC filed a motion

As a result of CAMC’s September 1999 report to the Board of Medi-

cine, the Board undertook an investigation into Wahi’s suspension and

ultimately filed a complaint against him in September 2001 to determine

whether disciplinary action should be taken regarding Wahi’s license to

practice medicine. After protracted proceedings, the Board of Medicine

ultimately dismissed the charges in November 2003 without reaching a

decision on the merits of the allegations. (J.A. 147-180, 254-55, 701.)

The claims against all but one of the other defendants, Dr. Crotty,

were subsequently dismissed from the suit, see R. 12 and 88, and are not

before us in this appeal.

8 WAHI v. CHARLESTON AREA MEDICAL CENTER

for summary judgment, which the district court construed as

a motion to dismiss pursuant to Rule 12(b)(6). (J.A. 48.) By

order dated October 27, 2004, the district court dismissed the

Sherman Act claims for failure to allege an effect on interstate

commerce, but granted Wahi leave to amend to remedy that

omission. (J.A. 59-61.) The district court also dismissed all

but one of Wahi’s § 1983 claims against CAMC, finding "ut-

terly without merit" Wahi’s assertion that CAMC acted

"under color of state law" because it reported him to the

NPDB. (J.A. 61-62.) Lastly, it dismissed Wahi’s state inva-

sion of privacy or wrongful disclosure claim, concluding that

"a plain reading of [the HCQIA] means that only the informa-

tion contained in a report to the [NPDB], and not the mere

fact that a report was made, is protected as confidential." (J.A.

63-64.)

Wahi then filed an amended complaint reiterating the

claims the district court had not dismissed in its October 2004

order, and amending the Sherman Act claims to include alle-

gations of an effect on interstate commerce. (J.A. 68-93.)

Wahi’s amended complaint alleged the following claims: (1)

Anti-Trust Conspiracy, in violation of the Sherman Act, 15

U.S.C. § 1 (2000); (2) Anti-Trust Monopolization, in violation

of the Sherman Act, 15 U.S.C.A. § 2 (West 1997 & Supp.

2008); (3) breach of contract and implied covenant of good

faith and fair dealing; (4) conspiracy to deny his constitutional

right to due process, in violation of 42 U.S.C.A. § 1983 (West

2005); (5) defamation; and (6) violation of his civil rights

under 42 U.S.C.A. § 1981 (West 2005).11 Wahi also sought a

declaration "that the reports made by [CAMC] to the NPDB

are invalid and contrary to law," the removal of CAMC’s "de-

rogatory reports concerning [Wahi] from the NPDB," the

reinstatement of Wahi’s hospital privileges, actual and puni-

tive damages, attorneys fees, and costs. (J.A. 92.) Wahi’s

overarching contention was that CAMC’s decisions to sus-

Additional claims were subsequently voluntarily dismissed and are not

at issue on appeal. (J.A. 12; R. 61.)

WAHI v. CHARLESTON AREA MEDICAL CENTER 9

pend him and deny his application for reappointment were

taken in bad faith to prevent competition by monopolizing the

field of cardiac surgery in the region and to prevent him from

practicing medicine. (J.A. 68-92.)

By order dated September 29, 2006, the district court

granted motions by CAMC and Dr. Crotty for summary judg-

ment on all counts. Wahi v. Charleston Area Med. Ctr., 453

F. Supp. 2d 942 (S.D.W. Va. 2006). (J.A. 262-91.) The court

held that CAMC qualified for immunity under the HCQIA

from all of Wahi’s claims for damages. In so doing, it ana-

lyzed each of the four components that a professional review

action must possess in order to qualify for immunity, as set

forth in 42 U.S.C. § 11112(a), and concluded that CAMC ful-

filled each requirement. Id. at 948-55. (J.A. 266-79.) Regard-

ing the fact that CAMC never held a hearing regarding

Wahi’s suspension, the district court found

that the evidence offered by Dr. Wahi is insufficient

for a reasonable jury to find that CAMC failed to ful-

fill its obligations under § 11112(a)(3) by a prepon-

derance of the evidence. The overwhelming

evidence is that CAMC acted in an objectively rea-

sonable manner in light of the totality of the circum-

stances in this case and took sufficient measures to

ensure Dr. Wahi received adequate notice of any

hearing or meeting that was to occur in the proposed

actions against him. The many letters between the

parties illustrate the hospital’s attempts to set a hear-

ing at Dr. Wahi’s request and give him notice of the

hearing. Dr. Wahi was represented by counsel

throughout the process and in the end, he was

informed and fully aware of his rights, the hospital’s

policies, and the charges and evidence the hospital

had against him. The hospital responded promptly

when Dr. Wahi requested a hearing be scheduled.

10 WAHI v. CHARLESTON AREA MEDICAL CENTER

Id. at 954. (J.A. 278.) The district court concluded the HCQIA

immunity protected CAMC against Wahi’s claims for viola-

tions of the Sherman Act, breach of contract,12 and defama-

tion. Id. at 955. (J.A. 279.) Recognizing that the HCQIA does

not afford immunity from claims for injunctive relief, the dis-

trict court dismissed those claims based on its conclusion that

"Wahi fail[ed] to make any argument or allege any facts that

would entitle him to injunctive relief."13 Id. at 960. (J.A. 289-

90.). The district court recognized that the HCQIA does not

provide immunity from claims alleging civil rights violations,

but granted CAMC summary judgment on Wahi’s § 1983

conspiracy to deny due process claim because "Wahi [did] not

offer even a scintilla of evidence that there was communica-

tion between CAMC and the Board of Medicine beyond that

required by law." Id. (J.A. 288-89.) Accordingly, the district

court awarded summary judgment to CAMC and dismissed

Wahi’s case with prejudice. Id. (J.A. 291.)

Wahi noted a timely appeal, (J.A. 292-93), and we have

jurisdiction under 28 U.S.C.A. § 1291 (West 2006).

II.

On appeal, Wahi’s primary argument is that the district

The district court also provided an alternative basis for the granting of

summary judgment as to Wahi’s breach of contract claim: CAMC com-

plied with the procedures outlined in its Procedures Manual and those

required by federal law, and that CAMC’s Bylaws did not constitute a

contract under West Virginia law, so any violation of the Bylaws could

not constitute a breach of contract. Id. at 955-56. (J.A. 280-82.)

It also held that Wahi’s § 1981 claim was barred by the applicable

statute of limitations and also failed on the merits because Wahi had not

proven CAMC’s race-neutral reason for its actions were pretextual. Id. at

957-60. (J.A. 282-88.) Because Wahi does not challenge the district

court’s disposition of this claim, it is not before us on appeal. See Fed. R.

App. P. 28(a)(9)(A); see also 11126 Baltimore Boulevard, Inc. v. Prince

George’s County, 58 F.3d 988, 993 n.7 (4th Cir. 1995) (en banc) (involv-

ing predecessor to Federal Rule of Appellate Procedure 28(a)(9)(A)).

WAHI v. CHARLESTON AREA MEDICAL CENTER 11

court erred in holding that CAMC14 was entitled to immunity

under the HCQIA even though CAMC summarily suspended

Wahi "without notice or a hearing." Wahi also contends that

the district court erred in dismissing his claims seeking

injunctive relief because the HCQIA only provides immunity

from suits for damages. In addition, Wahi challenges the dis-

trict court’s determination that CAMC was not a state actor

and therefore was not amenable to suit under 42 U.S.C.A.

§ 1983 (2005). Lastly, Wahi asserts the district court erred in

dismissing his state law defamation, breach of confidentiality,

and breach of contract claims. We address each argument

below.

A. HCQIA Immunity

Wahi asserts the district court erred in determining CAMC

was entitled to immunity under the HCQIA because CAMC

never held a hearing regarding Wahi’s suspension, and there-

fore did not satisfy the requirements for claiming immunity

under the Act. (Br. Appellant 18-30; Reply Br. 2-15.) How-

ever, we conclude the district court did not err in determining

CAMC was entitled to immunity under the particular facts of

this case.

The HCQIA provides a "professional review body"15 with

In his opening brief, Wahi states that he "is also appealing the dis-

missal of Dr. Crotty as a co-defendant," even though he refers to CAMC

as the "Appellant." (Br. Appellant 3.) The district court similarly analyzed

the claims against CAMC and Dr. Crotty together. We will invoke a simi-

lar convention, referring only to CAMC, but including Dr. Crotty in the

analysis for the claims Wahi brought against him.

"The term ‘professional review body’ means a health care entity and

the governing body or any committee of a health care entity which con-

ducts professional review activity, and includes any committee of the

medical staff of such an entity when assisting the governing body in a pro-

fessional review activity." 42 U.S.C.A. § 11151(11) (West 2005).

12 WAHI v. CHARLESTON AREA MEDICAL CENTER

immunity from damages whenever a "professional review

action"16 is taken:

(1) in the reasonable belief that the action was in the

furtherance of quality health care,

(2) after a reasonable effort to obtain the facts of the

matter,

(3) after adequate notice and hearing procedures are

afforded to the physician involved or after such other

procedures as are fair to the physician under the cir-

cumstances, and

(4) in the reasonable belief that the action was war-

ranted by the facts known after such reasonable

effort to obtain facts and after meeting the require-

ment of paragraph (3).

42 U.S.C.A. § 11112(a) (West 2005). "A professional review

action shall be presumed to have met the preceding standards

necessary for [immunity] unless the presumption is rebutted

by a preponderance of the evidence." Id.

A "professional review action" is:

an action or recommendation of a professional review body

which is taken or made in the conduct of professional review

activity, which is based on the competence or professional con-

duct of an individual physician (which conduct affects or could

affect adversely the health or welfare of a patient or patients), and

which affects (or may affect) adversely the clinical privileges, or

membership in a professional society, of the physician. Such term

includes a formal decision of a professional review body not to

take an action or make a recommendation described in the previ-

ous sentence and also includes professional review activities

relating to a professional review action.

42 U.S.C.A. § 11151(9) (West 2005).

WAHI v. CHARLESTON AREA MEDICAL CENTER 13

Due to the presumption of immunity under the HCQIA, a

court applies an "unconventional standard in determining"

whether summary judgment is appropriate — "whether a rea-

sonable jury, viewing all facts in a light most favorable to

[Wahi], could conclude that he had shown, by a preponder-

ance of the evidence, that [CAMC’s] actions fell outside the

scope of section 11112(a)." Gabaldoni v. Washington County

Hosp. Ass’n, 250 F.3d 255, 260 (4th Cir. 2001). In determin-

ing whether a health care entity has met these four require-

ments, the Court applies an objective test that "looks to the

totality of the circumstances" to determine whether the action

satisfies the § 11112(a) provisions. Imperial v. Suburban

Hosp. Ass’n, 37 F.3d 1026, 1030 (4th Cir. 1994).

In a footnote in his opening brief, Wahi contends that even

though the "primary focus of this appeal is the failure of

CAMC to schedule a hearing," as required under subsection

3 of § 11112(a), the "first, second and fourth prongs of the

test [for immunity under the HCQIA] were also not met." (Br.

Appellant 29 n.11.) Other than this declarative sentence, Wahi

fails to raise any argument to support his claim that the first,

second, and fourth prongs of the subsection (a) immunity

criteria were not met.17 Federal Rule of Appellate Procedure

28(a)(9)(A) requires that the argument section of an appel-

lant’s opening brief must contain the "appellant’s contentions

and the reasons for them, with citations to the authorities and

parts of the record on which the appellant relies." Because

Wahi has failed to comply with the specific dictates of Rule

28(a)(9)(A), we conclude that he has waived his claims as to

the first, second, and fourth requirements of the subsection (a)

HCQIA immunity test on appeal. See 11126 Baltimore Boule-

vard, Inc., 58 F.3d at 993 n.7 (involving predecessor to Fed-

eral Rule of Appellate Procedure 28(a)(9)(A)). Accordingly,

our review regarding the immunity issue is limited to whether

the district court erred in determining that Wahi did not over-

Unless otherwise indicated, references to "subsection __" will refer to

subsections of 42 U.S.C. § 11112.

14 WAHI v. CHARLESTON AREA MEDICAL CENTER

come the presumption that CAMC satisfied the requirements

of subsection (a)(3).

A health care entity is "deemed to have met the adequate

notice and hearing requirement of" § 11112(a)(3) when it sat-

isfies the safe harbor provisions of § 11112(b). Wahi argues

that because CAMC failed to follow the provisions of subsec-

tion (b), it does not qualify for immunity under the HCQIA.

However, as the district court properly recognized, (J.A. 275),

following the provisions of subsection (b) is but one way a

health care entity can comply with the requirements of sub-

section (a)(3). While a health care entity is "deemed to have

met" the subsection (a)(3) immunity requirements by follow-

ing the safe harbor provisions of subsection (b), those provi-

sions are not exclusive. "[F]ailure to meet the conditions

described [in subsection (b)] shall not, in itself, constitute fail-

ure to meet the standards of subsection (a)(3)." § 11112(b)(3).

Therefore, Wahi’s argument that CAMC is not entitled to

immunity, as a matter of law, because it did not comply with

all of the provisions in subsection (b), fails under the plain

language of the statute.

Wahi next asserts that CAMC is not entitled to immunity

because it failed to satisfy the exceptions from immunity

carved out in § 11112(c). Wahi contends that since CAMC

summarily suspended him for more than 14 days without first

finding that he posed an imminent danger to his patients and

without conducting a post-suspension investigation, CAMC

cannot claim immunity under the HCQIA. Wahi misreads the

statute. Subsection (c) sets forth limited circumstances in

which a health care entity can act with immunity without sat-

isfying all of the conditions in subsection (a). Subsection (c)

provides in pertinent part:

For purposes of section 11111(a) of this title, noth-

ing in this section shall be construed as –

(1) requiring the procedures referred to in subsec-

tion (a)(3) of this section –

WAHI v. CHARLESTON AREA MEDICAL CENTER 15

(A) where there is no adverse profes-

sional review action taken, or

(B) in the case of a suspension or restric-

tion of clinical privileges, for a period of

not longer than 14 days, during which an

investigation is being conducted to deter-

mine the need for a professional review

action; or

(2) precluding an immediate suspension or restric-

tion of clinical privileges, subject to subsequent

notice and hearing or other adequate procedures,

where the failure to take such an action may result

in an imminent danger to the health of any individ-

ual.

§ 11112(c).

Subsection (c) thus sets out distinct ways in which a health

care entity can be immune under the HCQIA without having

complied with the usual requirements for claiming immunity.

Wahi would have us read the statute by ignoring this clear

purpose and instead find that the HCQIA immunity is barred

by failing to meet one of the subsection (c) prongs. To the

contrary, subsection (c) presents additional routes to HCQIA

immunity beyond that set forth in subsection (a)(3). Although

Wahi may be correct that the facts show CAMC cannot assert

immunity based on (c)(1) or (c)(2), the only significance is

that CAMC must meet the usual standard of qualifying for

immunity set forth in subsection (a)(3).18

Under subsection (a)(3), a health care entity seeking

HCQIA immunity must act "after adequate notice and hearing

procedures are afforded to the physician involved or after

such other procedures as are fair to the physician under the

[REDACTED]

16 WAHI v. CHARLESTON AREA MEDICAL CENTER

circumstances." § 11112(a)(3) (emphasis added). Stated in the

disjunctive, the statute contemplates two independent avenues

by which the subsection (a) immunity prong may be obtained.

The first avenue, "adequate notice and hearing procedures," is

not at issue in the case at bar. CAMC makes no claim under

that prong and the district court did not consider it. What

CAMC argues, and the district court held, is that the unique

circumstances in this case show that Wahi received "other

procedures as are fair to the physician under the circum-

stances," and entitle CAMC to the HCQIA immunity.

Wahi cites the legislative history of subsection (a)(3) to

assert that the "other procedures" undertaken by a health care

entity must nonetheless include a hearing. In particular, Wahi

relies on this language from the 1986 House Report recom-

mending the adoption of the HCQIA:

The due process requirement [i.e., subsection (a)(3),]

can always be met by the procedures specified in

subsection (b). . . . If other procedures are followed,

but are not precisely of the character spelled out in

[subsection (b)], the test of "adequacy" may still be

met under other prevailing law. The Committee is

aware, for example, that some courts have already

carefully spelled out different requirements for cer-

tain professional review activities or actions, such as

procedures for decisions regarding applicants for

clinical privileges at a hospital. In those situations,

compliance with applicable law should satisfy the

"adequacy" requirement even where such activities

or actions require different or fewer due process

rights than the ones specified under [subsection (b)].

In any case, it is the Committee’s intent that physi-

cians receive fair and unbiased review to protect

their reputations and medical practices.

H.R. Rep. No. 99-903, at 10-11 (1986), as reprinted in 1986

U.S.C.C.A.N. 6384, 6393. Nothing in this legislative history

WAHI v. CHARLESTON AREA MEDICAL CENTER 17

alters the conclusion that a health care entity can satisfy sub-

section (a)(3) without providing a formal hearing, as contem-

plated in the safe harbor provisions, depending on the

circumstances of a particular case. Rather, Congress’ intent —

and that expressed by the plain language of the statute — is

that a physician be afforded adequate and fair "procedures"

with regard to professional review actions, which could be

something other than a formal hearing in some circumstances.

If this were not so, Congress would have no reason to have

included the "other procedures appropriate . . . under the cir-

cumstances" language contained in the statute in contrast to

the specific "notice and hearing" language.

Wahi also contends that CAMC’s failure to follow some of

the procedures outlined in its Bylaws and Procedures Manual

proves CAMC did not satisfy subsection (a)(3) under the

alternative prong. However, as the Court of Appeals for the

Fifth Circuit recently observed,

HCQIA immunity is not coextensive with compli-

ance with an individual hospital’s bylaws. Rather,

the statute imposes a uniform set of national stan-

dards. Provided that a peer review action . . . com-

plies with those standards, a failure to comply with

hospital bylaws does not defeat a peer reviewer’s

right to HCQIA immunity from damages.

Poliner v. Tex. Health Sys., 537 F.3d 368, 380-81 (5th Cir.

2008); see also Meyers v. Columbia/HCA Healthcare Corp.,

341 F.3d 461, 469-71 (6th Cir. 2003). Nothing in the subsec-

tion (a)(3) phrase "such other procedures as are fair . . . under

the circumstances" mandates by-law compliance as the sine

qua non for immunity, although from a practical standpoint,

by-law compliance may often be proof of such procedures in

many cases.

Having concluded that CAMC was not required to hold a

formal hearing as a mandatory condition precedent to satisfy-

18 WAHI v. CHARLESTON AREA MEDICAL CENTER

ing subsection (a)(3), we now examine whether the district

court properly determined CAMC provided Wahi with "such

other procedures as are fair . . . under the circumstances." We

begin that review by underscoring the unique procedural pos-

ture upon which summary judgment for a health care entity is

measured under the HCQIA, as the district court properly

summarized:

In applying the test outlined in § 11112(a), we begin

with the presumption that the hospital has met the

necessary standards for immunity unless this pre-

sumption is rebutted by a preponderance of the evi-

dence. § 11112(a). The applicable standard is one of

objective reasonableness, viewed in light of the total-

ity of the circumstances. Freilich[ v. Upper Chesa-

peake Health, Inc., 313 F.3d 205,] 212 [(4th Cir.

2002)] (quoting Imperial v. Suburban [Hosp. Ass’n],

37 F.3d 1026, 1030 (4th Cir. 1994)). Reasonableness

standards have been consistently upheld in the con-

text of qualified immunity. Freilich, 313 F.3d at 213.

Wahi, 453 F. Supp. 2d at 950. (J.A. 270.) We find no error in

the district court’s determination that Wahi failed to rebut the

presumption that CAMC’s actions satisfied the statutory

requirement when the totality of the circumstances are viewed

in an objectively reasonable manner.

[REDACTED] informed Wahi of the allegations from the

Credentials Committee by letter dated July 16 and further dis-

cussed them in a meeting with him on July 17. (J.A. 575-77.)

Moreover, Wahi apparently learned of the unauthorized sur-

gery allegation against him even prior to [REDACTED]’s

letter because on July 15, he wrote to [REDACTED] stating

he understood questions had arisen regarding his decision to

perform the procedure, explaining his decision to perform the

contested procedure, and setting forth why he believed it fell

within his clinical privileges. (J.A. 721-28.) Although

[REDACTED]’s July 16 letter does not mention a possible

WAHI v. CHARLESTON AREA MEDICAL CENTER 19

suspension, it does state that CAMC would be investigating

the claims that Wahi had again exceeded his authority under

his provisional privileges and not complied with the CAMC

Bylaws when he failed to notify CAMC that he had relin-

quished his privileges at another hospital. Wahi had previ-

ously been suspended at least three times for violation of his

privileges and was not unaware of the consequences.

[REDACTED] also informed Wahi that he should respond

in writing as soon as possible and address his reappointment

before the Credentials Committee at the August 3, 1999 hear-

ing, (J.A. 576), which was rescheduled for August 17 at

Wahi’s request. Over the next two weeks, Wahi wrote to

[REDACTED] and [REDACTED] several times, addressing

the charges in writing, and providing documents supporting

his position that he had not violated the conditions of his clin-

ical privileges. He also requested access to certain records

prior to or during the Credentials Committee meeting. (J.A.

730, 731, 732-41, and 742.) The record shows that CAMC

provided Wahi with notice of the most recent allegations

against him, and an opportunity to respond to those allega-

tions. CAMC complied with its Procedures Manual in this

regard.

CAMC suspended Wahi’s medical privileges by a letter

dated July 30, 1999 from [REDACTED], which recited the

"best interests of patient care" as the reason for the action.

(J.A. 586.) However, the record does not support Wahi’s con-

tention that CAMC did not inform him more specifically of

the reasons for his suspension. On July 30, [REDACTED]

and [REDACTED] met with Wahi to inform him of the sus-

pension pending the Credentials Committee’s review of his

application for reappointment. [REDACTED]’s memoran-

dum of that meeting recites that they informed Wahi that the

Credentials Committee and Board of Trustees both recom-

mended he be suspended. [REDACTED] cited Wahi’s "in-

ability to follow procedural guidelines outlined by the

Committee and the Board of Trustees which ensures adequate

20 WAHI v. CHARLESTON AREA MEDICAL CENTER

care and safety of patients," and also told Wahi that when he

met with the Credentials Committee, he should "be prepared

to defend his lack of adherence to the limitations on his privi-

leges as well as his absence of notification of suspension from

St. Francis [Hospital]."19 (J.A. 965.) The suspension letter reit-

erated the rights due Wahi under Article III of the Procedures

Manual for a hearing to challenge that action, and attached a

copy for his use.

The Credentials Committee then afforded Wahi, by letter of

August 13, 1999, the opportunity to review the file for the

August 17 meeting for the "timeline of events surrounding

[his] privileges" at CAMC. The letter also emphasized to

Wahi that

This meeting is your opportunity to present the Com-

mittee with additional information that is pertinent to

its evaluation of your ethical behavior, clinical com-

petence and clinical judgment in the treatment of

patients; compliance with Hospital policies and the

Medical Staff Bylaws and Rules and Regulations;

behavior in the hospital, your cooperation with medi-

cal and Hospital personnel as it relates to patient care

or the orderly operation of hospital, and your general

attitude toward patients, the Hospital and its person-

nel; use of the Hospital facilities for your patients;

your physical and mental health; your capacity to

satisfactorily treat patients as indicated by the results

of the Hospital’s quality assessment activities or

other reasonable indicators of continuing qualifica-

tions; your satisfactory completion of such continu-

ing education requirements as may be imposed by

law, the Hospital or applicable accreditation agen-

[REDACTED] and [REDACTED] also agreed that Wahi could con-

tinue treating two patients "currently in house" and that care of all of

Wahi’s patients would be transferred to another physician or discharged

by August 1, 1999. (J.A. 965.)

WAHI v. CHARLESTON AREA MEDICAL CENTER 21

cies; and other relevant findings from CAMC’s and

the Medical Staff’s quality assurance activities.

(J.A. 752.) Copies of relevant portions of CAMC’s Proce-

dures Manual were attached to the letter. (J.A. 752-57.) A

separate letter informed Wahi how the meeting would be con-

ducted, and set out Wahi’s rights regarding the meeting. (J.A.

719-20.)

The Credentials Committee met on August 17, 1999. Wahi

appeared before it and presented his case. The Committee

concluded it "was unable to identify evidence that Dr. Wahi’s

clinical competence [and] professional judgment . . . are suffi-

cient to recommend . . . that he be reappointed to the Medical

Staff."20 (J.A. 645-46.) In particular, the Committee cited the

following

• Failure to comply with and repeated violation of

clinical privileges (§ 3.7 of the Bylaws), includ-

ing:

° Failure to obtain a proctor when

required to do so;

° Failure to obtain a second opinion when

required to do so;

° Performance of an operative procedure

for which he did not have privileges.

• Marginal indications for operative procedures;

• Poor decision-making in the care of some

patients;

Denial of reappointment is a NPDB-reportable event. See 42 U.S.C.

§ 11133(a) (requiring health care entities to report "professional review

action[s] that adversely affect[ ] the clinical privileges of a physician for

a period longer than 30 days").

22 WAHI v. CHARLESTON AREA MEDICAL CENTER

• Multiple incident reports surrounding bizarre pro-

fessional behavior and inappropriate personal

behavior among nursing staff;

• Failure to comply with responsibilities set forth

in the CAMC Bylaws, including providing proper

quality of care (§ 3.2), maintaining proper medi-

cal records (§ 3.3), and notifying CAMC of the

loss of clinical privileges at any other hospital

(§ 3.6); and

• Failure to keep a current, complete, and timely

record of patient care (§§ 2.1 and 2.7 of the Med-

ical Staff Rules and Regulations) (J.A. 550, 552-

53).

(J.A. 645.)

On August 26, 1999, Wahi received the Credentials Com-

mittee report and was once again notified of the rights pro-

vided in Article III and that he had 30 days to request a hearing.21

(J.A. 647.) The letter also informed Wahi his suspension

remained in effect until the CAMC Board of Trustees acted

on his reappointment. (J.A. 647.) On September 8, 1999,

Wahi, by counsel, timely requested a hearing as well as a wit-

ness list and a number of specified documents. (J.A. 648-53.)

On October 18, 1999, CAMC notified Wahi of the mem-

bers of the hearing panel and asked Wahi to "work with the

presiding officer to schedule and conduct the hearing in

accordance with . . . Article III," and again forwarded Wahi

the Procedures Manual.22 (J.A. 654-55, 699-700.) CAMC did

Article III of the Procedures Manual set forth Wahi’s right to a hear-

ing based on both the summary suspension and the Credentials Commit-

tee’s recommendation to deny Wahi’s application for reappointment. (See

Procedures Manual 2.3.4.2, 2.4.3, 3.1; J.A. 484-87.)

The Procedures Manual stated that once a hearing is requested, the

President of CAMC "shall schedule the hearing and shall give notice of

its time, place and date . . . to the person who requested the hearing. The

hearing shall begin as soon as practicable, considering the schedules and

availability of all concerned, provided that [it] shall not begin without at

least thirty days notice." (Procedures Manual 3.6; J.A. 489.)

WAHI v. CHARLESTON AREA MEDICAL CENTER 23

not give Wahi a specific witness list,23 but afforded his coun-

sel access to some of the files requested in the September 8,

1999 letter. CAMC repeatedly requested that Wahi provide

available dates for his hearing because "the hearing will take

a number of days" and it was important to "select dates well

enough in advance that all involved parties can clear their

schedules." (J.A. 776.) In over 8 years since his request for a

hearing, Wahi has yet to provide CAMC with any dates when

he would be available for a hearing.

During the following year, the parties negotiated over how

the hearing would be conducted. Wahi objected to the compo-

sition of the panel, its presiding officer,24 and the use of any

incident or discipline during his medical practice at CAMC

that he did not address at the August 17, 1999 Credentials

Committee meeting. And while CAMC had opened many of

its files to Wahi and his counsel, some items Wahi had

requested had not been disclosed due to privacy disagree-

ments, which had not been resolved. The parties also

attempted to negotiate a resolution of the matter, including

withdrawing Wahi’s suspension based on a written statement

of the basis for CAMC’s actions. However, the parties were

unable to reach an agreement. (J.A. 760-83, 118-30.)

On November 30, 2000, Wahi filed an action in the West

Virginia state court to enjoin his requested hearing unless

CAMC met his pre-conditions. Wahi asked the state court to

order, inter alia, that his method of selection for the hearing

Section 3.7 of the Procedures Manual states that CAMC should have

provided a list of witnesses to Wahi "within ten days" of his request, and

that the witness list could be supplemented or amended in the discretion

of the presiding officer of the hearing, provided that notice of the change

has been given. (J.A. 489.)

The Procedures Manual provides that the President of CAMC "shall

appoint a panel of not less than three members, none of whom are in direct

competition with the individual who requested the hearing," after consid-

ering the recommendations of the Chief of Staff and the Chairman of the

Board." (Procedures Manual 3.8; J.A. 489.)

24 WAHI v. CHARLESTON AREA MEDICAL CENTER

panel be used, that no matters of Wahi’s medical practice at

CAMC be considered at the hearing except those mentioned

in [REDACTED]’s July 30, 1999 letter, and that the court

maintain "jurisdiction over the administrative hearing." (J.A.

99, 112, 99-114.)

The state court rejected Wahi’s arguments and dismissed

the complaint, stating Wahi’s arguments were speculative and

"[i]t would be premature for the Court to make any determi-

nation as to whether or not the notice given to Dr. Wahi satis-

fies the ‘fair procedures’ requirement." (J.A. 141.)

Furthermore, the court noted that the composition of the hear-

ing panel was in conformity with CAMC’s Procedures Man-

ual, and that any objections about the hearing panel or the

evidence to be considered should be raised before the hearing

panel. The court entered its final order of dismissal on

December 6, 2001.

In the meantime, the West Virginia Board of Medicine filed

a complaint against Wahi on September 10, 2001, and set a

hearing "to determine whether disciplinary action should be

taken . . . against Dr. Wahi’s license to practice medicine."

(J.A. 149.) Wahi and the Board of Medicine engaged in pro-

tracted litigation, which included Wahi’s unsuccessful attempt

to halt the proceedings by seeking a writ of prohibition

against the Board of Medicine from the Supreme Court of

Appeals of West Virginia. On November 10, 2003, the pro-

ceedings were dismissed, without a final disposition on the

merits of the allegations. (J.A. 147-175, 701.) Wahi made no

effort during this time period to pursue a hearing at CAMC.

While CAMC argues this was a deliberate choice by Wahi to

prevent a hearing that would create a record that could affect

the Board of Medicine proceedings, the district court made no

finding in that regard, CAMC assigns no error to the lack of

a finding, and we therefore do not consider it. The next action

in time was the filing of Wahi’s complaint in the district

court.

WAHI v. CHARLESTON AREA MEDICAL CENTER 25

Lastly, in considering whether the procedures provided by

the health care entity are fair "under the circumstances," the

July 1999 allegations against Wahi cannot be considered in a

vacuum. These allegations were simply the latest in Wahi’s

tumultuous history with CAMC, as the August 26, 1999 Cre-

dentials Committee letter set forth. Since his reappointment in

1995, Wahi had been the subject of numerous reports and

complaints calling his professional competence and conduct

into question. The record shows that these complaints arose

from a multitude of discrete incidents, were made by different

individuals, and were known to Wahi. After all Wahi had

been through the suspension process previously at CAMC,

including the prior reports to the NPDB. CAMC investigated

and imposed restrictions, including temporary suspensions, as

a result of those investigations. Wahi was aware of the conse-

quences for failing to abide by the Bylaws and Procedures

Manual. He was not a first-time offender who was unfamiliar

with the responsibilities of his position at CAMC or the con-

sequences for his failures in July 1999. (J.A. 130-31, 248-53,

339-97, 496-571.)

While CAMC’s path to immunity in this case is not a rec-

ommended model, it must be evaluated considering all the

events which transpired, not just those Wahi views as favor-

able to him. Had CAMC simply set a prompt hearing, what-

ever Wahi’s objections and efforts to stop it, CAMC may

have been within its rights to do so and may have met the first

prong of subsection (a)(3). Similarly, CAMC should have fol-

lowed its Bylaws and the Procedures Manual, and provided

Wahi a witness list, even if it had to be later supplemented.

However, these failures by CAMC, when viewed in the total-

ity of the circumstances against a measuring stick of objective

reasonableness, do not show Wahi met his burden of proof to

rebut the presumption of immunity under the HCQIA. Wahi

was on notice of the many charges against him, including the

detailed Credentials Committee report of August 26, 1999. He

was repeatedly notified of his rights and given multiple copies

of documents explaining these rights. He was repeatedly

26 WAHI v. CHARLESTON AREA MEDICAL CENTER

asked for dates for a hearing. While CAMC attempted to

accord Wahi a hearing in conformity with the Procedures

Manual, Wahi seemed more intent on forestalling a hearing

than having one.

Had Wahi proceeded to a hearing, any complaint about the

inadequacy of notice, defective witness list or discovery, the

composition of the hearing panel, the conduct of the hearing,

or other relevant issues could have been addressed and sub-

jected to judicial review. In the face of Wahi’s recalcitrance,

it is at the least disingenuous to now claim his right to a hear-

ing was infringed when he has done all he could do not to

have a hearing. Viewing the totality of these circumstances in

an objectively reasonable manner, we cannot conclude that

the district court erred in determining Wahi failed to rebut the

presumption that CAMC afforded him "other procedures as

are fair to the physician under the circumstances." We there-

fore affirm the district court’s holding that CAMC is entitled

to immunity under the HCQIA.

B. Injunctive Relief

Wahi also contends the district court erred in awarding

summary judgment25 as to his claims for injunctive relief

because "[a]lthough the HCQIA immunize[d] [CAMC and

Dr. Crotty] from claims for monetary damages, that statutory

immunity does not apply to injunctive relief." (Br. Appellant

25.) He asserts he has satisfied the requirements for obtaining

an injunction requiring CAMC to provide him a hearing and

We review the district court’s grant of summary judgment on this

issue de novo. Hill v. Lockheed Martin Logistics Mgmt., Inc., 354 F.3d

277, 283 (4th Cir. 2004) (en banc). "Summary judgment is appropriate if

the pleadings, depositions, answers to interrogatories, and admissions on

file, together with the affidavits, if any, show that there is no genuine issue

as to any material fact and that the moving party is entitled to a judgment

as a matter of law." Id. (internal quotation marks omitted). We construe

the evidence in the light most favorable to Wahi, the party opposing the

Appellees’ motion, and draw all reasonable inferences in his favor. See id.

WAHI v. CHARLESTON AREA MEDICAL CENTER 27

remove his name from the NPDB list because he cannot

acquire gainful employment so long as his name is on the

NPDB list, monetary damages will not restore his ability to

practice, and the public possesses a strong interest in ensuring

hospitals abide by the law. (Br. Appellant 25-26; Reply Br.

17-20.)

The HCQIA only provides immunity from suits for dam-

ages. 42 U.S.C. § 11111(a)(1); see Imperial, 37 F.3d at 1030-

31. The district court expressly recognized this limitation, and

it did not base its decision that Wahi was not entitled to

injunctive relief on CAMC’s immunity under the HCQIA.

(J.A. 289-90.) Instead, it concluded Wahi "fail[ed] to make

any argument or allege any facts that would entitle him to

injunctive relief." Wahi, 453 F. Supp. 2d at 960. (J.A. 289-

90.)

The district court did not err in this determination. In order

to pursue injunctive relief to redress his Anti-Trust, breach of

contract, and defamation claims, Wahi must have a viable

claim that CAMC committed a wrong.

[A] remedy must be tailored to a violation [and] the

nature of the violation determines the scope of the

remedy. Remedies, in other words, do not exist in

the abstract; rather, they flow from and are the con-

sequence of some wrong. At its most basic, this prin-

ciple limits the reach of judicial decrees to parties

found liable for a legal violation.

See Bacon v. City of Richmond, 475 F.3d 633, 638 (4th Cir.

2007) (quoting Swann v. Charlotte-Mecklenburg Bd. of Educ.,

402 U.S. 1, 16 (1971)) (internal quotation marks and citations

omitted). Wahi has not made the requisite showing for any of

the claims for which the district court determined the HCQIA

immunity applied. The district court provided non-HCQIA-

based reasons for awarding CAMC summary judgment on

28 WAHI v. CHARLESTON AREA MEDICAL CENTER

Wahi’s breach of contract and defamation claims, which

Wahi has also appealed, and which we discuss below.

Lastly, even if Wahi succeeded on the merits of his Anti-

Trust claims, he would not be entitled to the injunctive relief

he sought in his amended complaint. Wahi’s amended com-

plaint asked for an injunction directing CAMC "to remove its

derogatory reports concerning Dr. Wahi from the NPDB" and

"to reinstate Dr. Wahi’s hospital privileges." (J.A. 92.) This

relief is not connected to any alleged acts of anti-competitive

behavior by CAMC.

C. State Actor

Wahi asserts the district court erred in determining CAMC

was not a state actor, as that term is contemplated under

§ 1983, and therefore not amenable to suit under that statute.26

(Br. Appellant 12-15; Reply Br. 21-22.) To state a claim

under § 1983, a plaintiff must aver that a person acting under

As noted, the district court dismissed all but one of Wahi’s § 1983

claims in its October 27, 2004 order granting CAMC’s motions under

Rule 12(b)(6). Therefore, we conduct a de novo review of the district

court’s decision, Mylan Labs, Inc. v. Matkari, 7 F.3d 1130, 1134 (4th Cir

1993), accepting all allegations in Wahi’s complaint as true. Republican

Party v. Martin, 980 F.2d 943, 952 (4th Cir. 1992). To survive a Rule

12(b)(6) motion, "[f]actual allegations must be enough to raise a right to

relief above the speculative level" and have "enough facts to state a claim

to relief that is plausible on its face." Bell Atl. Corp. v. Twombly, 127 S.

Ct. 1955, 1965, 1974 (2007). Moreover, the court "need not accept the

[plaintiff’s] legal conclusions drawn from the facts," nor need it "accept

as true unwarranted inferences, unreasonable conclusions, or arguments."

Kloth v. Microsoft Corp., 444 F.3d 312, 319 (4th Cir. 2006) (internal quo-

tation marks omitted).

Wahi challenges the district court’s determination that CAMC was not

itself a state actor, but he makes no argument related to the September 29,

2006 order dismissing his conspiracy-based § 1983 claim based on a fail-

ure to show any evidence that CAMC conspired with the state Board of

Medicine. Accordingly, our review is limited to the § 1983 claims dis-

missed in the district court’s October 2004 order.

WAHI v. CHARLESTON AREA MEDICAL CENTER 29

color of state law deprived him of a constitutional right or a

right conferred by a law of the United States. See Dowe v.

Total Action Against Poverty, 145 F.3d 653, 658 (4th Cir.

1998). "Like the state-action requirement of the Fourteenth

Amendment, the under-color-of-state-law element of § 1983

excludes from its reach ‘merely private conduct, no matter

how discriminatory or wrongful.’" Am. Mfrs. Mut. Ins. Co. v.

Sullivan, 526 U.S. 40, 50 (1999). Consequently, "[t]he person

charged must either be a state actor or have a sufficiently

close relationship with state actors such that a court would

conclude that the non-state actor is engaged in the state’s

actions." DeBauche v. Trani, 191 F.3d 499, 506 (4th Cir.

1999). "[P]rivate activity will generally not be deemed ‘state

action’ unless the state has so dominated such activity as to

convert it to state action: ‘Mere approval of or acquiescence

in the initiatives of a private party’ is insufficient." Id. at 507;