Gibbons v. Secretary of Health and Human Services

In the United States Court of Federal Claims No. 18-531 (Filed Under Seal: July 2, 2026) (Reissued: July 20, 2026) 1 ************************************** MALINDA GIBBONS, * * Petitioner, * * v. * * SECRETARY OF HEALTH AND HUMAN * SERVICES, * * Respondent. * ************************************** Richard Gage, Richard Gage, P.C., Cheyenne, WY, counsel for Petitioner. Debra A. Filteau Begley, U.S. Department of Justice, Civil Division, Washington, DC, counsel for Respondent. OPINION AND ORDER DIETZ, Judge. Petitioner Malinda Gibbons seeks review of Special Master (“SM”) Christian J. Moran’s decision denying her petition for compensation under the National Childhood Vaccine Injury Act of 1986, 42 U.S.C. §§ 300aa-1 et seq. (“Vaccine Act”). She alleges that she developed Guillain- Barré Syndrome-Miller Fisher Variant (“GBS-MFV”) as a result of a tetanus-diphtheria-acellular pertussis (“Tdap”) vaccine she received on April 19, 2016. Because Ms. Gibbons has not demonstrated that the SM’s decision was arbitrary, capricious, an abuse of discretion, or not in accordance with law, the Court DENIES her petition and SUSTAINS the SM’s decision. I. BACKGROUND 2 Ms. Gibbons was born in 1969. Gibbons, 2025 WL 4481312, at *1. In January of 2013, she sought treatment from her gynecologist “for a bulge in her vagina, pelvic pressure, urinary 1 Pursuant to Vaccine Rule 18(b) of the Rules of the United States Court of Federal Claims, the Court issued this Opinion and Order under seal on July 2, 2026, and provided the parties fourteen days to propose redactions. See [ECF 176]. The parties did not propose any redactions. Accordingly, the Court reissues this Opinion and Order without redactions. 2 The factual background is derived from the SM’s decision. See Gibbons v. Sec’y of Health & Hum. Servs., 2025 WL 4481312 (Fed. Cl. Dec. 10, 2025). frequency and urgency, and incontinence.” Id. At the time, her gynecologist diagnosed “her as having a mild cystourethrocele,” or “protrusion of the bladder and urethra into the vagina.” Id. One year later, in January of 2014, Ms. Gibbons emailed her primary care physician (“PCP”), complaining of “numbness and tingling in [her] neck and chin” over a period of several days. Id. (internal quotation marks omitted) (alteration in original). At an in-person appointment with her PCP later that month, she “stated that these symptoms were aggravated by stress and alleviated by a hot bath.” Gibbons, 2025 WL 4481312, at *1. In March of 2014, Ms. Gibbons went to another doctor regarding “her three-month history of tingling along her neck and into her face.” Id. at *2. She underwent a cervical x-ray, which showed that she suffered from “mild degenerative disease.” Id. Ms. Gibbons returned to her PCP on April 19, 2016, complaining of “chronic and progressively worsening urinary urgency and frequency.” Gibbons, 2025 WL 4481312, at *2 (internal quotation marks omitted). At that appointment, she received a prescription for overactive bladder medication and the Tdap vaccine that is the subject of the instant petition. Id. In the weeks following her receipt of the Tdap vaccine, “Ms. Gibbons continued to complain about and seek medical attention for her bladder problems.” Id. On May 15, 2016, she called her PCP and described her symptoms as follows: “tingling all over body . . . . Yesterday developed gum tingling, now legs, feet, scalp tingling. Unsteady feeling.” Id. (internal quotation marks omitted). The next day, May 16, 2016, Ms. Gibbons had an appointment with a urologist, who “stated that she had urinary retention of unclear etiology.” Gibbons, 2025 WL 4481312, at *2. On May 17, 2016, “Ms. Gibbons sought care in an emergency room [(“ER”)] due to numbness throughout her body and vertigo.” Id. Upon examination, she was found to have “reduced sensation in her upper extremities,” and bulging “tympanic membranes.” Id. “[S]he was diagnosed with a bilateral ear infection, prescribed antibiotics, and released.” Id. One day later, “Ms. Gibbons reported a two-day history of vertigo [triggered by eye movements] and difficulty walking.” Id. After testing, “[s]he was prescribed lorazepam and amoxicillin” for a urinary tract infection. Id. Ms. Gibbons’ urinary tract infection persisted through May 20, 2016, and she once more sought treatment in the ER. Gibbons, 2025 WL 4481312, at *2. While there, she complained of “vertigo, nausea, vomiting, and whole-body numbness,” and “was admitted for further testing.” Id. “Her motor and strength exams were normal[,] . . . [h]owever, her deep tendon reflexes were diminished at all sites.” Id. Further, “[s]he could not track any movement with her eyes because her eyes were fixed.” Id. Dr. Howard Noack, a neurologist, “evaluated Ms. Gibbons on May 22, 2016.” Id. Although “Ms. Gibbons could not move her right eye and had moderate movement in her left eye[, h]er strength, sensation, and deep tendon reflexes were normal.” Id. “Dr. Noack did not ‘know what to make of diffuse tingling and numbness[.]’” Id. He considered whether she was suffering from GBS-MFV but noted that Ms. Gibbons had “normal deep tendon reflexes.” Id. He therefore referred her case to an ophthalmologist, who “stated that Ms. Gibbons did not have any meaningful eye movement.” Id. While “[i]n the hospital, Ms. Gibbons[] again experienced urinary retention and a catheter was placed.” Id. at *3. Her “May 25, 2016[,] discharge report included urinary retention as a problem.” Id. Ms. Gibbons later testified “that during the May 2016 hospitalization, she had tingling in her ‘face, legs, and toes, and cramping in her mid-back.’” Id. 2  On June 7, 2016, Ms. Gibbons saw Dr. Kenneth Kubis, a neuro-ophthalmologist. Gibbons, 2025 WL 4481312, at *3. She complained of “continued dizziness and difficulty focusing near and far.” Id. “Dr. Kubis observed eye weakness and mild ptosis,” 3 and “suspected that Ms. Gibbons might have the Miller Fisher variant.” Id. He therefore “ordered a test for the GQ1b antibody.” Id. One week later, Ms. Gibbons saw Dr. Vidya Hawkins, a neurologist. Id. She complained of double vision and difficulty with walking. Id. Like Dr. Kubis, Dr. Hawkins suspected that Ms. Gibbons could have “atypical MFS.” Id. She therefore “recommended a three-day trial of IVIG.” Id. Ms. Gibbons tested positive for GQ1b antibodies. Id. On June 22, 2016, Ms. Gibbons saw another doctor for increased blood pressure. Gibbons, 2025 WL 4481312, at *3. According to the notes taken by that doctor, the “working diagnosis [was] Miller Fisher variant.” Id. (internal quotation marks omitted). On June 27, 2016, Ms. Gibbons began “[a] three-day course of IVIG.” Id. At her follow up appointment with Dr. Hawkins, Ms. Gibbons reported “that the IVIG treatments had helped . . . [and] that she felt 95% back to normal with improvements in her double vision and balance.” Id. She also reported, however, “that her problems worsened in the heat.” Id. “Dr. Hawkins diagnosed Ms. Gibbons as suffering from GBS-MFV” but “did not order any further neurologic treatment,” and “recommended that Ms. Gibbons see a urologist for her urinary symptoms.” Id. Ms. Gibbons later testified that she saw Dr. Hawkins for “double vision and difficulty balancing.” Id. at *4. She also testified “that her eyes fatigued easily, [that] she was experiencing general fatigue” and “that she was not having leg cramps and/or toe cramps.” Id. Ms. Gibbons returned to Dr. Kubis on August 9, 2016. Gibbons, 2025 WL 4481312, at *4. This time, “[s]he stated that her double vision and ptosis had resolved in July.” Id. Additionally, “[s]he reported that she felt ‘much better and near normal unless [she got] overheated[, in which case, she had] to sit down.” Id. “Dr. Kubis examined her and found that her eye weakness and ptosis [were] ‘now resolved,’” and “recommended neurology follow ups as needed.” Id. Ms. Gibbons later testified “that around this time, she was experiencing episodes of double vision that lasted longer than one minute, once or twice per week.” Id. On August 29, 2016, Ms. Gibbons saw Dr. Michelle Koski, a urologist. Gibbons, 2025 WL 4481312, at *4. “She described her history of urinary retention and frequency, including occasional accidents.” Id. Dr. Koski examined her, found “evidence of urethral prolapse,” 4 and “prescribed estrogen.” Id. According to Dr. Koski, “Ms. Gibbons denied fatigue.” Id. Ms. Gibbons later testified “that the medical record was accurate to her knowledge,” but that she “did not recall being asked about fatigue and . . . would not [have told] a urogynecologist about fatigue.” Id. At some point in 2016, Ms. Gibbons emailed Dr. Kubis, complaining of “blurry vision in her right eye.” Gibbons, 2025 WL 4481312, at *4. “She asked if blurry vision could be related to GBS-MFV,” and Dr. Kubis “stated that it ‘shouldn’t be,’ and recommended that she see an 3 “‘Ptosis’ is a medical term for drooping eyelids.” Gibbons, 2025 WL 4481312, at *3. 4 “A urethral prolapse, also known as urethrocele, is ‘prolapse of the urethral mucosa’ and is ‘a diverticulum of the urethral walls encroaching upon the vaginal canal.’” Gibbons, 2025 WL 4481312, at *3. 3 optometrist.” Id. Ms. Gibbons later testified “that she [had] a regular eye doctor at Redhawk Vision.” Id. On January 16, 2017, Ms. Gibbons emailed Dr. Hawkins. Gibbons, 2025 WL 4481312, at *5. She complained of “increased urinary retention, tingling in her gums and jaw, and [said] she was concerned she may be having a relapse of GBS.” Id. The next day, in a conversation with a nurse from Dr. Hawkins’s office, “Ms. Gibbons clarified that her tingling sensation lasted only half of a day and resolved, [and that] she had no vision problems, but she did report a recent increase in stress.” Id. Ms. Gibbons had a CT scan on January 22, 2017, which “revealed that a large mass was displacing [her] uterus and bladder.” Gibbons, 2025 WL 4481312, at *5. During her “preoperative evaluation, Ms. Gibbons reported ‘continued mild fatigue with no current paresthesias or neurologic sequelae.’” Id. Ms. Gibbons had surgery on February 16, 2017. Id. At that point, “[t]he mass was identified as a ‘large left ovarian cyst . . . that completely filled the pelvis.’” Id. “The surgeons removed both of Ms. Gibbons’s ovaries and her left fallopian tube.” Id. On February 17, 2017, “Ms. Gibbons emailed her surgeon to ask about estrogen patches and progesterone,” and her “surgeon stated that she could start those medications right away.” Id. The surgeon also stated that adjustments could be made at a later time “to make ‘sure you do not have strong hot flashes.’” Id. On March 13, 2017, Ms. Gibbons saw Dr. Meredith McMullen, her gynecologist. Gibbons, 2025 WL 4481312, at *5. She told her “that she was taking Climara as a form of [hormone replacement therapy (‘HRT’)]” and “did not report any symptoms of menopause.” Id. “Dr. McMullen recommended that Ms. Gibbons continue her HRT.” Id. Ms. Gibbons later testified “that after the operation, she could have been experiencing fatigue” and “was limited in her activities.” Id. On March 22, 2017, she told “Dr. McMullen that she was menstruating . . . and asked whether this was normal.” Id. Dr. McMullen told her that “bleeding can occur” when an individual starts HRT, but that “[a]fter the hormone levels stabilize, the bleeding will stop.” Id. Ms. Gibbons refilled her Climara on July 3, 2017, and she refilled her progesterone on May 21, 2018. Id. Ms. Gibbons emailed Dr. Hawkins on May 4, 2017, and reported heat intolerance, stating that she ‘walked around at a street festival last week where it was 75 degrees and almost passed out[.]’” Gibbons, 2025 WL 4481312, at *5. She also stated that “she was ‘sure [it was] related to [her] nerves’ and her GBS-MFV.” Id. Dr. Hawkins told her that she “should avoid environments with excess heat.” Id. Ms. Gibbons later testified “that she did not tell Dr. Hawkins about her hormone replacement therapy,” but “expected that Dr. Hawkins would know about the hormone replace therapy because it was documented in her medical records.” Id. at *6. In addition, Ms. Gibbons “stated that heat intolerance has a ‘gradual onset.’” Id. In her view, heat intolerance is characterized by a “shortness of breath, nausea, and a sense that she needs to sit down before she falls down,” whereas “a hot flash brings about sudden heat and sweating without lasting fatigue.” Id. Her recollection of being at the street festival was that she “experienced dizziness in the context of almost passing out,” and “was also fatigued.” Id. 4  In June 2017, Ms. Gibbons traveled from California to North Carolina to visit her parents.” Gibbons, 2025 WL 4481312, at *6. Thereafter, “[o]n September 7, 2017, Ms. Gibbons sought care from a mental health provider for anxiety and possible depression.” Id. She reported “low energy, sleep problems, [] a history of depression,” and “trouble staying asleep,” and wondered if the cause was hormonal. Id. “When reporting her current medications, she only noted Ativan, and when asked if she took any over the counter medications, her response was ‘you name it . . . [.]’” Id. Ms. Gibbons saw Dr. Hawkins on September 12, 2017, and “reported trouble with sleep, daytime fatigue, anxiety, intermittent tingling in her perioral region, and an increased need for ‘screening breaks since GBS.’” Gibbons, 2025 WL 4481312, at *6. Dr. Hawkins found “no objective neurological deficits,” upon examination and “prescribed a trial of nortriptyline for paresthesia.” 5 Id. Also, “he explained that a ‘[c]oexisting mood disorder likely influence[d] her symptoms.’” Id. (first alteration in original). Ms. Gibbons later testified “that she had begun experiencing tingling in her perioral region in May 2016” and that “[w]hen she talked to Dr. Hawkins in September 2017, [she] was experiencing the tingling several times per day with episodes ranging from a few minutes to a few hours.” Id. In her view, “[t]he tingling in her perioral region [prompted her] to take breaks from using screens because she was worried that she was having a relapse of GBS.” Id. In addition, she explained her reported “daytime fatigue,” as “whole body fatigue after basic daily activities, such as going to the grocery store.” Id. Ms. Gibbons further testified that the “[t]his fatigue started in May 2016,” that she did not have “leg cramps and/or toe cramps” and that she “did not recall having dizziness.” Id. On October 4, 2017, Ms. Gibbons saw her therapist. Gibbons, 2025 WL 4481312, at *7. At that visit, she “reported concerns with fatigue and sleep issues.” Id. She also told her therapist that she had been written “a recent prescription for nortriptyline, but she did not fill that prescription.” Id. She told her therapist she was taking “melatonin and Ativan” and stated “that she did not list her HRT because these medications were irrelevant to an appointment for mental health concerns.” Id. Ms. Gibbons later testified “that the fatigue was preventing her from doing ‘many activities with [her] daughter and [her] family’” and that “[s]he was taking breaks during the day.” Id. She further “stated that for hormone replace therapy, she was using ‘Climara estrogen patches, P[r]ometrium progesterone, and Estrace vaginal cream.’” Id. Ms. Gibbons was seen for a weight management program on October 16, 2017, and she reported that she exercised three days a week at a moderate or strenuous level.” Gibbons, 2025 WL 4481312, at *7. She later testified that she “had recorded information about her exercises in a notebook, [but] she no longer possesse[d] it.” Id. “On February 24, 2018, Ms. Gibbons called Dr. McMullen to discuss hormone concerns,” noting that “[s]he had been lifting weights for four months, [but] her body had not changed.” Gibbons, 2025 WL 4481312, at *7. Three months later, she saw another “provider associated with her PCP for unrelated concerns.” Id. Ms. Gibbons told this provider “that she uses Climara once a week, but that she ran out and [was] getting more.” Id. She further stated that “[s]he only uses Estrace as needed and the record states that she was not taking 5 “Nortriptyline is an anti-depressive medication that is also used to relieve chronic, severe pain.” Gibbons, 2025 WL 4481312, at *6. 5 progesterone.” Id. Ms. Gibbons “explained that she was currently using a cream . . . and [that] she was considering restarting progesterone.” Id. “When asked about this cream, Ms. Gibbons stated that she was using progesterone cream as that form was better for her than progesterone pills.” Id. “On July 19, 2018, Ms. Gibbons” again saw Dr. McMullen, who documented that she was using “[an] estradiol patch 0.05 mg/24h, applied once weekly, [oral] micronized progesterone 200 mg/d and estradiol vaginal cream.” Gibbons, 2025 WL 4481312, at *7. During this visit, “Ms. Gibbons complained of low libido and requested testosterone.” Id. Following an examination, Dr. McMullen noted that Ms. Gibbon’s vagina was “normal appearing, suggesting an estrogen effect in the vagina.” Id. “Dr. McMullen [also] documented that they reviewed hormone replacement therapy [] in detail” and Ms. Gibbons indicated that she “wanted to switch to oral meds.” Id. Dr. McMullen continued “[h]er other HRT medications, including estrogen patch[es], oral micronized progesterone and vaginal estrogen cream.” Id. “On March 25, 2019, Ms. Gibbons saw [Dr.] Cynthia Sorrell [] for complaints of bilateral cramping in her legs and toes that began a few days earlier and reoccur[ed] upon exertion.” Gibbons, 2025 WL 4481312, at *8. At that point, “[s]he was working out on an elliptical for 20 minutes a day, and during the last few days she [had] experienced cramping in the backs of her legs and toes.” Id. Ms. Gibbons told Dr. Sorrell “that she [had] experienced muscle cramping and an electrolyte disturbance when she was diagnosed with GBS.” Id. They reviewed the medications she was taking and “Ms. Gibbons explained that she stopped taking oral prometrium due to her belief that it caused irregular bleeding, but [stated that] she was using a Climara patch.” Id. Dr. Sorrell noted “abnormal vaginal bleeding, and bilateral leg cramping.” Id. She ordered lab tests “to check Ms. Gibbons’s electrolytes and . . . urged [her] to talk with her gynecologist about changes to her HRT.” Id. Ms. Gibbons later testified “that these leg and toe cramps ‘started intermittently in 2017.’” Id. In retrospect, Ms. Gibbons “rated them as 7 or 8 in severity with 10 being a maximum. She also stated that one month after this report, she ‘probably’ still had leg and toe cramps[, although] she [did] not remember any specific incidents.” Id. In addition, “Ms. Gibbons also connect[ed] this March 25, 2019[,] leg cramping to her earlier neurologic disorder.” Id. “Also on March 25, 2019, [Ms. Gibbons] emailed Dr. Hawkins and reported issues with a headache, cramping, and nausea, and feeling dehydrated.” Gibbons, 2025 WL 4481312, at *8. Ms. Gibbons “stated that when she had GBS-MFV, she ‘had trouble with [her] sodium potassium balance’ and [indicated] that ‘this [felt] like the same thing.’” Id. (first alteration in original). Dr. Hawkins recommended that she “try taking over-the-counter magnesium, and if that [did] not work, she could take muscle relaxers.” Id. Ms. Gibbons later testified that “she [did] not recall whether she was experiencing tingling in her perioral region, fatigue, or dizziness” at the time. Id. The next day, “Ms. Gibbons emailed Dr. Sorrell and expressed concern that her labs showed low electrolytes[.]” Id. “Ms. Gibbons was told that while she had a borderline low chlorine, she should not be concerned unless she [was] experiencing active diarrhea[.]” Id. She was also told that “her results were otherwise normal.” Id. “Her PCP reviewed the same labs and agreed that they were normal and suggested that Ms. Gibbons take a potassium tablet for one week to help with her cramping.” Id. Two days later, Ms. Gibbons again saw Dr. Hawkins. Id. This time, she reported suffering from “leg cramping that was waking her at night.” Id. Dr. Hawkins “noted that 6 she [did] not drink much water and that her electrolyte panel was normal.” Id. Dr. Hawkins also “stated that a history of GBS may pre-dispose a person to cramping, and [] recommended increased hydration and magnesium supplements.” Id. “On April 30, 2019, Ms. Gibbons saw Dr. McMullen.” Gibbons, 2025 WL 4481312, at *9. Dr. McMullen “noted that [Ms. Gibbons] was previously prescribed both progesterone and Climara, [] that ‘she does not consistently use the progesterone,’ [that] ‘[s]ometimes she does not use the estrogen consistently either,’ and [that] she ‘occasionally uses over-the-counter progesterone lotion.’” Id. (fourth alteration in original). “Dr. McMullen [also] noted that Ms. Gibbons was not taking any medications at the time of this appointment.” Id. She told Ms. Gibbons that she “should take HRT as prescribed, including simultaneous use of progesterone and Climara.” Id. In addition, Dr. McMullen “changed Ms. Gibbons’s progesterone to Prometrium 100mg, and recommend[ed] she also continue the Climara patch.” Id. “She [also] cautioned Ms. Gibbons that if she did not take her medication as directed, she could experience spotting.” Id. “On August 7, 2020, . . . Ms. Gibbons emailed Dr. Hawkins and stated that she was having more severe foot and leg cramps, and she was still taking magnesium and drinking mineral water.” Gibbons, 2025 WL 4481312, at *9. Ms. Gibbons “asked what other prescription drugs were recommended and she [also] asked for a mental health counselor in Escondido.” Id. “Baclofen was recommended.” 6 Id. Ms. Gibbons later testified that this was the “second time that a medical record documents a complaint about leg cramps with the first instance being a March 25, 2019[,] instance.” Id. “Ms. Gibbons saw or spoke to her PCP twice more in 2020 and reported no relevant issues.” Id. “In March 2021, Ms. Gibbons emailed Dr. Hawkins about the COVID vaccines and saw an allergist about the same concerns.” Id. She “did not report any GBS-MFV complaints” at that time. Id. “In August 2021, Ms. Gibbons asked her PCP for a letter supporting her need to cancel a gym membership” and “[i]n January 2022, Ms. Gibbons sought care for an unrelated issue.” Id. On April 11, 2018, Ms. Gibbons sought compensation under the Vaccine Act. Pet. for Vaccine Compensation [ECF 1]. She alleged that she contracted GBS-MFV from a Tdap vaccine. Id. ¶¶ 2-6. The SM found that Ms. Gibbons failed to demonstrate that her GBS-MFV lasted for more than six months and thus failed to satisfy the Vaccine Act’s severity requirement. Gibbons, 2025 WL 4481312, at *1. Therefore, on December 10, 2025, the SM denied Ms. Gibbons’s request for compensation. Id. at *22. Ms. Gibbons appealed his decision on February 10, 2026. Mem. of Objections [ECF 172]. The government responded on March 12, 2026. Resp’t’s Mem. in Resp. to Pet’r’s Mot. for Review [ECF 174]. The petition is fully briefed, and the Court held oral argument on June 25, 2026. II. STANDARD OF REVIEW The United States Court of Federal Claims has jurisdiction under the Vaccine Act to review a special master’s decision. 42 U.S.C. § 300aa-12(e)(2). In conducting its review, the Court may: 6 “Baclofen is a medication to relax muscles.” Gibbons, 2025 WL 4481312, at *9. 7  (A) uphold the findings of fact and conclusions of law of the special master and sustain the special master’s decision, (B) set aside any findings of fact or conclusion of law of the special master found to be arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law and issue its own findings of fact and conclusions of law, or (C) remand the petition to the special master for further action in accordance with the court’s direction. 42 U.S.C. § 300aa-12(e)(2)(A)-(C). The Court reviews a special master’s findings of fact under the “arbitrary and capricious” standard, legal questions under the “not in accordance with law” standard, and discretionary rulings under the “abuse of discretion” standard. Turner v. Sec’y of Health & Hum. Servs., 268 F.3d 1334, 1337 (Fed. Cir. 2001) (citing 42 U.S.C. § 300aa–12(e)(2)(B); Munn v. Sec’y of Health & Hum. Servs., 970 F.2d 863, 870, 870 n.10 (Fed. Cir. 1992)). With respect to the arbitrary and capricious standard, “no uniform definition . . . has emerged,” but it is “a highly deferential standard of review” such that “[i]f the special master has considered the relevant evidence of record, drawn plausible inferences and articulated a rational basis for the decision, reversible error will be extremely difficult to demonstrate.” Hines v. Sec’y of Health & Hum. Servs., 940 F.2d 1518, 1527-28 (Fed. Cir. 1991); accord Motor Vehicle Mfrs. Ass’n of U.S., Inc. v. State Farm Mut. Auto Ins. Co., 463 U.S. 29, 43 (1983) (stating that a decision is arbitrary and capricious if it is “so implausible that it could not be ascribed to a difference in view”); Cedillo v. Sec’y of Health & Hum. Servs., 617 F.3d 1328, 1338 (Fed. Cir. 2010) (“We do not sit to reweigh the evidence. [If] the Special Master’s conclusion [is] based on evidence in the record that [is] not wholly implausible, we are compelled to uphold that finding as not being arbitrary or capricious.” (internal quotation marks and citation omitted) (alterations in Cedillo)). The “not in accordance with law” standard, on the other hand, is applied without deference to legal determinations. Deribeaux v. Sec’y of Health & Hum. Servs., 717 F.3d 1363, 1366 (Fed. Cir. 2013); see Munn, 970 F.2d at 870 (stating that “[i]ssues of law—constitutional imperatives, statutory construction, procedural requirements—come to [the court] for decision with little if any deference owed to or expected by the forums below”). Lastly, the abuse of discretion standard applies to the special master’s evidentiary rulings, such as determinations regarding the qualification of experts and the admissibility of their testimony. Piscopo v. Sec’y of Health & Hum. Servs., 66 Fed. Cl. 49, 53 (2005) (citing Kumho Tire Co. v. Carmichael, 526 U.S. 137, 152 (1999)). “The [abuse of discretion standard] will rarely come into play except where the special master excludes evidence.” Munn, 970 F.2d at 870 n.10; accord Caves v. Sec’y of Health & Hum. Servs., 100 Fed. Cl. 119, 131 (2011), aff’d, 463 F. App’x 932 (Fed. Cir. 2012). III. LEGAL STANDARDS “Under the Vaccine Act, Congress established a Vaccine Injury Compensation Program through which claimants could petition to receive compensation for vaccine-related injuries.” Markovich, 477 F.3d at 1356 (citing 42 U.S.C. § 300aa-10(a)). As a threshold matter, a petitioner 8 must prove, by a preponderance of the evidence, 7 that she satisfies five elements in order to establish a prime facie case. See 42 U.S.C. § 300aa-11(c)(1)(A)-(E); see also Walther v. Sec’y of Health & Hum. Servs., 485 F.3d 1146, 1150 (Fed. Cir. 2007) (stating that a petitioner has the burden of establishing the elements of 42 U.S.C. § 300aa-11(c)(1)). Two of these five elements are causation and severity. See id. § 300aa-11(c)(1)(C), (D). There are two ways for a petitioner to establish causation under the Vaccine Act. Munn, 970 F.2d at 865. First, a petitioner may demonstrate causation through a statutorily prescribed presumption by showing that the alleged injury meets the criteria listed on the Vaccine Injury Table (“Table”). See 42 U.S.C. § 300aa- 11(c)(1)(C)(i). The Table identifies the covered vaccines, the corresponding injuries, and the time period after vaccination in which the particular injuries must occur. See 42 C.F.R. § 100.3. “[I]f a petitioner can establish that she received a listed vaccine and experienced such symptoms or injuries within the specified timeframes, she has met her prima facie burden to prove that the vaccine caused her injuries.” de Bazan v. Sec’y of Health & Hum. Servs., 539 F.3d 1347, 1351 (Fed. Cir. 2008). Alternatively, if a petitioner suffered an injury listed on the Table but not within the specified time period or if a petitioner suffered an “off-Table injury,” she must prove “causation in fact” by a preponderance of the evidence. See Broekelschen v. Sec’y of Health & Hum. Servs., 618 F.3d 1339, 1341-42 (Fed. Cir. 2010) (citing Moberly v. Sec’y of Health & Hum. Servs., 618 F.3d 1339, 1342 (Fed. Cir. 2010); 42 U.S.C. § 300aa-11(c)(1)(C)(ii)). There are three ways for a petitioner to establish severity under the Vaccine Act. 42 U.S.C. § 300aa-11(c)(1)(D). To establish severity, a petitioner who suffers an injury from a vaccine must demonstrate that she “(i) suffered the residual effects or complications of such . . . injury[] or condition for more than 6 months after the administration of the vaccine, or (ii) died from the administration of the vaccine, or (iii) suffered such . . . injury[] or condition from the vaccine which resulted in inpatient hospitalization and surgical intervention[.]” Id. With respect to the requirement that the petitioner suffer the residual effects or complications of the injury for more than six months after administration of the vaccine, the Federal Circuit has held that such requirement “is a condition precedent to filing a petition for compensation” and that it “is intended to restrict eligibility to the compensation program.” Cloer v. Sec’y of Health & Hum. Servs., 654 F.3d 1322, 1335 (Fed. Cir. 2011); see also Wyatt v. Sec’y of Health & Hum. Servs., 144 Fed. Cl. 531, 539 (2019) (stating that a petitioner must “show by a preponderant evidence” that she meets the six-month severity requirement), aff’d, 825 F. App’x 880 (Fed. Cir. 2020). This requirement ensures that compensation under the Vaccine Act is made available only to those individuals who are seriously injured by a vaccine. Cloer, 654 F.3d at 1335. In evaluating a petitioner’s alleged residual effects, “it is axiomatic that if there is no connection between [the injury] and [the alleged residual effects], there [are] no ‘residual effects or complications’ that lasted for more than six months,” and the petitioner has not satisfied the severity requirement. Song v. Sec’y of Health & Hum. Servs., 31 Fed. Cl. 61, 66 (1994), aff’d, 41 F.3d 1520 (Fed. Cir. 1994). The special master or court may not find that a petitioner satisfies the 7 “Compensation shall be awarded under the Program to a petitioner if the special master or court finds . . . that the petitioner has demonstrated by a preponderance of the evidence the matters required in the petition by section 300aa-11(c)(1) of this title.” 42 U.S.C. § 300aa-13(a)(1)(A). “This court has interpreted the ‘preponderance of the evidence’ standard referred to in the Vaccine Act as one of proof by a simple preponderance, of ‘more probable than not’ causation.” Althen v. Sec’y of Health & Hum. Servs., 418 F.3d 1274, 1279 (Fed. Cir. 2005) (citing Hellebrand v. Sec’y of Health & Hum. Servs., 999 F.2d 1565, 1572-73 (Fed. Cir. 1993)). 9 requirements based solely on the petitioner’s claims, unsubstantiated by medical records or opinion. 42 U.S.C. § 300aa-13(a)(1). Once the petitioner has established a prima facie case for entitlement to compensation, the burden shifts to the government to prove “[by] a preponderance of the evidence that the [petitioner’s injury] is due to factors unrelated to the administration of the vaccine described in the petition.” de Bazan, 539 F.3d at 1352 (quoting 42 U.S.C. § 300aa-13(a)(1)(B); Walther, 485 F.3d at 1150); accord Doe v. Sec’y of Health & Hum. Servs., 601 F.3d 1349, 1357 (Fed. Cir. 2010) (“While the burden of proving a prima facie case is on the petitioner, the government has the burden of showing the injury or death was caused by a ‘factor unrelated.’” (quoting 42 U.S.C. § 300aa-13(a)(1)(B) then citing de Bazan, 539 F.3d at 1352-54; Walther, 485 F.3d at 1150)). IV. ANALYSIS Ms. Gibbons challenges the SM’s finding that her GBS-MFV did not satisfy the Vaccine Act’s severity requirement and argues that she “continued to suffer residual effects from her GBS for years after her injury.” [ECF 172] at 8. 8 In addition, she argues that she provided ample “proof of her ongoing residual symptoms [in the form of] . . . the expert report of a neurologist, and an endocrinologist, medical literature that report[ed] post GBS symptom[s], and [] the opinions of her treating doctors.” Id. According to Ms. Gibbons, the SM “dismissed . . . the opinions of her treating doctors and her experts and disregarded the supporting medical literature,” id., with respect to three of her GBS-MFV symptoms—gum tingling, leg cramps, and heat sensitivity, id. at 9, 15, 19. 9 For the reasons stated below, the Court concludes that Ms. Gibbons has not shown that the SM’s decision was arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law. A. Gum Tingling Ms. Gibbons argues that, while the SM acknowledged that the gum tingling she experienced on May 15, 2016, was the beginning of her neurologic symptoms of GBS-MFV, he failed to recognize that the gum tingling she experienced in 2017 was also caused by the vaccine. [ECF 172] at 10. Further, she argues that the SM erroneously “blamed her 2017 gum tingling on an episode of tingling from 2014,” id., a conclusion she argues was “both factually wrong and legal error,” id. at 11. According to Ms. Gibbons, whereas the gum tingling she experienced in 2016 was undoubtedly caused by GBS-MVF, “what caused the skin tingling in 2014 that was alleviated by hot bath” was unknown. Id. at 12. In addition, Ms. Gibbons contends that the SM inappropriately offered his own unsupported medical opinion when he discounted Dr. Steinman’s conclusion “that the cause of [her] gum tingling in 2017 was ‘that the cranial nerve that was attacked during the acute phase of the GBS had not yet fully healed,’” id. at 13, and 8 All page numbers cited from the filings on the docket refer to the page numbers generated by the CM/ECF system. 9 According to the SM, Ms. Gibbons identified “several problems” that allegedly were caused by her GBS-MFV. Gibbons, 2025 WL 4481312, at *13. They “include the following: tingling, fatigue, leg cramps, eye strain, heat sensitivity, and anxiety/depression.” Id. In the instant petition for review, Ms. Gibbons only challenges the SM’s conclusions as to three of her symptoms. 10 when the SM instead reasoned that “[i]f the nerve were not healed, then it seems more reasonable to expect that the damaged nerve would cause problems frequently and more consistently,” id. at 14. Lastly, Ms. Gibbons challenges the SM’s reliance on the testimony of Dr. Dara Jamieson, one of the government’s expert witnesses, who opined that her January 2017 gum tingling was not proof that her GBS-MFV symptoms lasted more than three months. Id. at 14. In Ms. Gibbons’s view, the SM’s implication that her 2017 gum tingling “was in fact the same as her 2014 symptom . . . would constitute an attempt by [the government] at a factor unrelated defense[, . . . and it would therefore be the government’s] burden to apportion between the two potential causes and prove that the GBS was not a cause.” Id. at 14-15. The Court finds that the SM considered the relevant record evidence before him, drew plausible inferences, and articulated a rational basis for his decision. Although Ms. Gibbons argues that the SM’s conclusion regarding the cause of her gum tingling in 2017 was legally and factually wrong, what she is really arguing is that the SM should have credited the testimony of Dr. Steinman, her expert witness, over that of Dr. Jamieson, the government’s expert witness. In fact, the SM considered both expert witnesses’ testimony on the subject and explained why he reached the conclusions he did. See Gibbons, 2025 WL 4481312, at *13-*14. First, the SM explained why he found that “Dr. Steinman’s opinion [was] based upon a selective and incomplete review of the medical records.” Id. at *14. According to the SM, “Dr. Steinman relied exclusively upon the January 2017 email exchange between Ms. Gibbons and the office of her neurologist,” in support of his opinion that Ms. Gibbons met the Vaccine Act’s severity requirement. Id. at *13. This is significant to the SM because Dr. Steinman failed to account for a 2014 incident during which Ms. Gibbons experienced “tingling in the context of stress,” which is similar to what she experienced in 2017 when she “reported tingling in her jaw, [and] she also reported stress.” Id. at *14. In addition, the SM noted that Dr. Steinman failed to grapple with Ms. Gibbons’s statement in January 2017 to her “neurologist’s nurse that the ‘tingling sensation only lasted [a] half day.’” Id. This is significant to the SM because, unlike Dr. Steinman, Dr. Jamieson directly addresses Ms. Gibbons’s statement by concluding that “the ‘report of hours of transient sensory complaints absolutely does not indicate a duration of MFS symptoms beyond 3 months.’” Id. Next, the SM explained why he was not persuaded by Dr. Steinman’s opinion “that the ‘most likely cause of the 2017 symptom is that the cranial nerve that was attacked during the acute phase of [Ms. Gibbons’s] GBS had not yet fully healed.’” Id. According to the SM, Dr. Steinman failed to “persuasively explain[] why there appears to be only two episodes of tingling after August 2016, separated by approximately eight months.” Id. The SM also noted that “Dr. Steinman’s opinion that [Ms. Gibbons’s] nerves had not completely healed is inconsistent with her report to Dr. Hawkins on June 16, 2016[,] that she was not having any numbness and tingling.” Id. Further, although Ms. Gibbons argues that it is the government’s “burden to apportion between the two potential causes [of her gum tingling] and prove that the GBS was not a cause,” [ECF 172] at 15, that burden only arises after a petitioner establishes a prima facie case by satisfying the elements in § 300aa-11(c)(1), see Doe, 601 F.3d at 1358 (finding that the burden never shifted to the government to establish an alternative cause because the petitioner failed to establish a prima facie case). 10 Here, the SM addressed Ms. Gibbons’s gum tingling in the 10 Once the petitioner has satisfied her burden under the causation element by providing “medical evidence relating to the possible role the vaccine had in causing her injury,” de Bazan, 539 F.3d at 1353-54, the government must