Court Opinion

ID: 9889772
Source: CourtListenerOpinion
Date Created: 2023-10-11 16:01:12.27791+00
Date Added: 2024-06-11T12:48:57.216349
License: Public Domain

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                                                              [PUBLISH]
                                   In the
                 United States Court of Appeals
                         For the Eleventh Circuit

                          ____________________

                                No. 20-10150
                          ____________________

        RICKY J. JOHNSON,
                                                      Plaintiﬀ-Appellant,
        versus
        DR. SHARON LEWIS,
        Statewide Medical Director of Georgia Department of
        Corrections,
        DR. THOMAS FERRELL,
        Medical Director of Ware State Prison
        DR KEVIN MARLER,
        Medical Director of Jenkins Correctional Facility,

                                                  Defendants-Appellees.
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        2                       Opinion of the Court                 20-10150

                              ____________________

                   Appeal from the United States District Court
                       for the Middle District of Georgia
                    D.C. Docket No. 5:16-cv-00453-TES-MSH
                            ____________________

        Before JORDAN, NEWSOM, Circuit Judges, and GRIMBERG, * District
        Judge.
        GRIMBERG, Circuit Judge:
               Ricky Johnson is an inmate in the custody and care of the
        Georgia Department of Corrections (GDC). Johnson was
        diagnosed with Hepatitis C (HCV) in 2009, but did not receive
        medication for it until nine years later. By then, Johnson’s HCV had
        progressed to stage F4 cirrhosis with indications of severe liver
        inflammation. Johnson sued numerous prison doctors, three of
        whom are the subject of this appeal, alleging that they were
        deliberately indifferent to his serious medical needs in violation of
        the Eighth Amendment. The district court granted summary
        judgment in favor of the doctors and dismissed all claims against
        them. Johnson appealed both the district court’s grant of summary
        judgment and its denial of his motion to amend the complaint.
        Because we find that material disputes of fact remain as to the
        doctors’ actions and inactions in treating Johnson, we reverse the

        *
         The Honorable Steven D. Grimberg, U.S. District Judge for the North-ern
        District of Georgia, sitting by designation.
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        20-10150                Opinion of the Court                           3

        district court’s grant of summary judgment but affirm its denial of
        the motion to amend.
                                         I
               The factual disputes in this case are manifold, and we
        construe the disputed matters in favor of Johnson, the nonmoving
        party. But before delving into the facts, some background on both
        HCV and the GDC’s policy for treating it are in order.
               HCV is a bloodborne virus that attacks a person’s liver. In
        particular, it can cause liver scarring, or “fibrosis”. Liver fibrosis is
        measured on a five-step scale, in ascending order of severity: F0 (no
        fibrosis); F1 (mild fibrosis); F2 (moderate fibrosis); F3 (severe
        fibrosis); F4 (cirrhosis). Cirrhosis is the most extreme form of liver
        damage, and can potentially result in liver cancer or liver failure.
        There are also grades of liver inflammation that can (but need not)
        correlate with the severity of the fibrosis. To monitor the
        progression of HCV infections, the standard of care is for doctors
        to use bloodwork to measure two enzymes, ALT and AST, that are
        released when the liver is damaged. While progression of the
        disease is often slow, it can also be unpredictable. It can take
        anywhere from months to decades to progress from one stage to
        the next. Irrespective of the progression rate, chronic HCV can be
        cured only with medication. It will not clear on its own.
               The GDC has a policy for treating patients with HCV, which
        has and continues to evolve as new treatments and medicines
        become available. Because the relevant time period in this case
        spans from 2012-2018, two GDC policies are at issue: the 2012
        policy and the 2016 policy. The 2012 policy provided for the
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        4                      Opinion of the Court               20-10150

        administration of a triple-drug treatment when patients met certain
        criteria, including a liver biopsy showing stage 2 fibrosis and grade
        2 inflammation. The policy also provided for exceptions, stating
        that it was

               not intended to be a substitute for professional
               judgment by the managing physician,
               [gastrointestinal], or [infectious disease]
               consultant. Treatment is always to be
               individualized base[d] on any unique patient
               factors.

                In other words, patients who did not meet the testing
        criteria could still qualify for treatment if approved by the
        managing physician or other professionals overseeing the patient’s
        care.
                In August 2016, the GDC updated its policy to account for
        the availability of newer, more effective treatments than the triple-
        drug regimen. The 2016 policy differed from the 2012 policy in a
        few relevant ways. First, it recognized a new class of HCV antiviral
        drugs. Second, it required the administration of a FibroSure test
        instead of a liver biopsy as part of a patient’s treatment eligibility
        determination. Finally, it created three priority levels for
        treatment, with medication generally reserved for Priority 1
        patients as determined by their FibroSure results.
                With that background in mind, we turn now to Johnson’s
        medical treatment or lack thereof. When Johnson was diagnosed
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        20-10150                  Opinion of the Court                               5

        with HCV in 2009, he was serving his sentence at Wilcox State
        Prison and under the medical care of Dr. Charles Ruis, who is not
        a party to this appeal. At that time, the progression of Johnson’s
        disease was mild and did not qualify him for treatment under either
        the GDC policy or the independent judgment of Dr. Ruis. Over the
        course of the next two years, Dr. Ruis continued to monitor
        Johnson’s condition. In January 2012, Dr. Ruis referred Johnson to
        a gastroenterologist and HCV specialist, Dr. Ayaz Chaudhary, who
        is also not a party to this appeal. While it is unclear what exactly
        triggered Dr. Ruis’s referral, he noted on the consultation request
        form that “[JOHNSON] HAS HCV AND WANTS TREATMENT”
        and “PLEASE CONSIDER FOR HCV TREATMENT.”
                On November 1, 2012, Dr. Chaudhary prescribed Johnson
        the triple-drug treatment and enrolled him in the prison’s clinic for
        treatment of chronic diseases. 1 Dr. Chaudhary’s decision to
        prescribe the triple-drug treatment is critical to the parties’ dispute
        on summary judgment. They agree that, at the time
        Dr. Chaudhary wrote the prescription, Johnson’s lab results did not
        qualify him for treatment under the 2012 policy. The parties do,
        however, dispute why Dr. Chaudhary issued the prescription
        anyway. Defendants cite Dr. Chaudhary’s affidavit, which states
        that he prescribed the medication based on Johnson’s perceived
        litigiousness, his advocacy for treatment, and out of an abundance

        1
               The parties disagree about whether Dr. Chaudhary prescribed
               Johnson the treatment in November 2012 or April 2013, but because
               there is contradictory evidence on this point we construe all inferences
               in Johnson’s favor for summary judgment purposes.
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        6                     Opinion of the Court               20-10150

        of caution. Johnson rightly points out that none of these reasons is
        noted in the contemporaneous documentation of Dr. Chaudhary’s
        prescription. Johnson counters that the prescription was medically
        warranted and based on Dr. Chaudhary’s professional judgment at
        the time, which is consistent with the 2012 policy. Regardless of the
        reason, Johnson did not receive his first dose until over five years
        later.
               Johnson was transferred to Hays State Prison in December
        2012, and in March 2013, to Ware State Prison and into the primary
        care of Defendant-Appellee Dr. Thomas Ferrell, the Medical
        Director at Ware. Dr. Ferrell is an internal medicine physician;
        while he is generally familiar with HCV, by his own admission he
        does not have the expertise to determine whether a particular
        patient should receive treatment for HCV.
               Dr. Ferrell first saw Johnson on April 1, 2013. During that
        visit, Dr. Ferrell continued filling out Johnson’s pre-therapy
        checklist, which Dr. Ruis started in 2009 and was required by the
        2012 policy to be completed before a patient could begin receiving
        treatment. The checklist in turn required that a patient have
        current blood lab results before starting HCV treatment.
        Dr. Ferrell concluded that Johnson’s blood labs from 2009 were
        aged and needed to be updated before Johnson could receive HCV
        treatment. So, Dr. Ferrell scheduled a follow-up appointment for
        Johnson with Dr. Chaudhary and ordered updated lab work.
               According to Dr. Chaudhary, this follow-up occurred on
        April 25, 2013. During that appointment, Dr. Chaudhary again
        recommended that Johnson begin the triple-drug treatment for his
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        20-10150              Opinion of the Court                       7

        HCV. At that time Dr. Chaudhary discussed with Johnson that
        missing even a few doses of the medications could cause the
        treatment to fail. This was particularly relevant because Johnson
        was scheduled to temporarily relocate to a different prison within
        a few days of the April 25 appointment. According to
        Dr. Chaudhary, due to this impending relocation he and Johnson
        agreed to wait to begin the treatment until Johnson returned to
        Ware State Prison.
               Johnson returned to Ware in August 2013. No treatment
        followed. This time, Dr. Ferrell attributed the delay to Johnson’s
        upcoming hernia surgery, scheduled for October 2013. Dr. Ferrell’s
        notes from September 16, 2013, state that “after surgery [HCV
        treatment] will be pursued.” Johnson underwent hernia surgery on
        October 1, 2013, and returned from the hospital to Ware on
        October 8, 2013. He spent no time in the recovery unit and took
        no pain medication other than Tylenol. Nonetheless, Dr. Ferrell
        attributes Johnson’s hernia surgery as the reason he did not begin
        receiving any HCV treatment for at least eight months.
               Frustrated by the delay, Johnson filed a grievance complaint
        on May 9, 2014. According to the Ware Grievance Coordinator,
        Johnson’s grievance complaint was denied because he “never
        discussed or inquired about treatment for Hepatitis.” Johnson
        appealed, detailing the history of his HCV care. Defendant-
        Appellee Dr. Sharon Lewis, the GDC’s Statewide Medical Director,
        denied Johnson’s appeal on the ground that “medical personnel
        handled this case appropriately.”
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        8                     Opinion of the Court              20-10150

               Even while his grievance complaint was pending, Johnson
        continued to seek medical care for his HCV. Following an
        appointment on May 28, 2014, Dr. Ferrell noted that Johnson was
        “ready to start [his prescription]” and scheduled another consult
        with Dr. Chaudhary. Another two months passed before this
        consultation occurred.
               On July 31, 2014, Johnson finally saw Dr. Chaudhary but
        now, a new obstacle arose. Dr. Chaudhary explained to Johnson
        that the availability of newer, more effective HCV drugs was
        imminent. According to Dr. Chaudhary, both he and Johnson
        agreed that pursuing the triple-drug therapy he had prescribed in
        2012 was no longer the best course of action. Johnson recalls this
        conversation but not any agreement on his part to delay treatment.
        Regardless, Dr. Chaudhary withdrew the outstanding prescription
        and recommended continued monitoring as well as a repeat liver
        biopsy to take place one year later, in July 2015.
               Shortly before the date of the recommended repeat liver
        biopsy, on May 21, 2015, Johnson was transferred to Jenkins
        Correctional Facility, a CoreCivic privately-owned prison. This
        transfer also meant that Johnson was now out of Dr. Ferrell’s care
        and into the care of Defendant-Appellee Dr. Kevin Marler, the
        Medical Director of Jenkins. Johnson saw Dr. Marler for the first
        time in early July 2015. At that time, Dr. Marler reviewed lab work
        and records for Johnson, and conducted a physical exam. Johnson’s
        ALT reading was 119 and his AST reading was 64, both of which
        fell outside of the normal range. Nevertheless Dr. Marler contends
        that, while abnormal, these levels were to be expected for a patient
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        20-10150               Opinion of the Court                        9

        with HCV. Dr. Marler notified Johnson that he would be placed in
        Jenkins’ chronic clinic, but would not receive drug therapy.
        Johnson informed Dr. Marler that he had already been prescribed
        HCV treatment and asked when it would begin. According to
        Johnson, Dr. Marler told him he would consult with GDC doctors
        about the treatment. Despite Johnson’s follow-ups, Dr. Marler
        never reported hearing back from GDC.
                Johnson continued to be monitored by Dr. Marler every six
        months, but the liver biopsy Dr. Chaudhary recommended to take
        place by July 2015 never occurred. Instead, during Johnson’s first
        chronic care visit on January 4, 2016, he presented with a skin rash,
        including scattered lesions on his extremities, which were treated
        with hydrocortisone cream. During Johnson’s second chronic care
        visit on June 28, 2016, blood work was done. While Johnson’s ALT
        and AST scores are not noted, Dr. Marler indicated that the APRI
        score “did not indicate a level of liver involvement then requiring
        treatment.”
                Sometime in August 2016, the updated GDC HCV policy
        that required the FibroSure test came into effect. But Dr. Marler
        did not give Johnson a FibroSure test that year. It was Dr. Lewis
        who, in April 2017, reminded Dr. Marler that the GDC had added
        the test to its HCV protocol. The parties are not aware of what
        prompted this communication. It was not until June 11, 2017—at
        Johnson’s next scheduled chronic care visit—that Dr. Marler finally
        administered a FibroSure test. Johnson’s raw score was 0.91,
        indicating cirrhosis. His inflammatory markers also indicated
        severe inflammation.
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        10                    Opinion of the Court               20-10150

                The parties fervently dispute how Dr. Marler responded to
        these results. Johnson contends that for at least a month, the doctor
        did absolutely nothing. He avers that it was not until July 11 that
        Dr. Marler finally began Johnson’s pre-therapy checklist and
        (retroactively) completed his notes from the June 11 appointment.
        On July 16, Dr. Marler ordered an abdominal ultrasound to
        determine whether the FibroSure test results were an accurate
        reflection of the severity of Johnson’s HCV. Ultimately, the
        ultrasound neither confirmed nor dispelled the FibroSure test’s
        indication of cirrhosis.
                On the other hand Dr. Marler contends that, after receiving
        Johnson’s FibroSure test results, he immediately ordered an offsite
        consult for HCV, noting that the results showed “stage F4 cirrhosis
        and needs prompt evaluation for treatment.” In a July 2017 email,
        Dr. Marler wrote to Dr. Keith Ivens (CoreCivic’s Chief Medical
        Officer), Dr. Lewis, and one additional doctor that Johnson’s
        “pretreatment eval is nearly completed with only an abdominal
        [ultrasound] remaining, that has been scheduled.” Dr. Marler
        asserted that he promptly submitted Johnson’s case for completion
        of the evaluation process. However, Dr. Marler fails to explain why
        nothing happened between early August, when he received the
        results of Johnson’s ultrasound, and November 2, when Johnson
        was transferred yet again, this time to Coffee Correctional Facility
        and out of Dr. Marler’s care. Nor does Dr. Marler offer an
        explanation as to why Johnson was transferred to a new facility at
        this time.
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        20-10150               Opinion of the Court                       11

               According to Johnson, his transfer occurred under nefarious
        circumstances. Frustrated by the continued lack of treatment,
        Johnson filed a second grievance complaint on October 10, 2017.
        The grievance was denied, and two days later, citing an
        unexplained “Inmate on Staff Conflict,” Johnson was transferred to
        Coffee. Johnson contends the transfer was in retaliation for filing
        the second grievance complaint.
               Once at Coffee, which was another private facility overseen
        by CoreCivic, Dr. Guy Augustin took over Johnson’s care. Dr.
        Augustin informed Johnson that he would attempt to start
        treatment. While the record lacks specific details about the
        circumstances, Johnson was again denied treatment in December
        2017.
               Johnson filed this suit in October 2016, which prompted
        CoreCivic’s lawyers to get involved. In late January 2018, they
        asked Dr. Augustin to provide Johnson’s treatment history.
        Dr. Augustin emailed a medical history summary to Dr. Lewis on
        January 29. A few hours later, she responded asking “WHO
        reviewed and refused treatment? What care has been provided
        since 2012?” Dr. Augustin then provided Dr. Lewis with a history
        of Johnson’s detention facility transfers since 2012. The following
        morning, Dr. Ivens, CoreCivic’s Chief Medical Officer, wrote to a
        three-member doctor team, stating that Dr. Lewis had “expressed
        concern about this case.” He also noted that there was a “clear
        case” that Johnson be classified as a Priority 1 patient and to “make
        provisions for treatment ASAP.” Johnson finally received his first
        dose of HCV treatment in mid-February 2018.
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        12                      Opinion of the Court                 20-10150

                                               II

               “We review a district court’s grant of summary judgment de
        novo, applying the same legal standards applied by the district
        court.” Valley Drug Co. v. Geneva Pharms., 344 F.3d 1294, 1303 (11th
        Cir. 2003) (citing Bailey v. Allgas, Inc., 284 F.3d 1237, 1242 (11th Cir.
        2002)).
               Johnson claims that Drs. Ferrell, Lewis, and Marler violated
        his Eighth Amendment right to be free from cruel and unusual
        punishment. U.S. Const. amend. VIII. The Supreme Court has held
        that, because this amendment prohibits “the unnecessary and
        wanton infliction of pain,” Estelle v. Gamble, 429 U.S. 97, 104 (1976)
        (quoting Gregg v. Georgia, 428 U.S. 153, 173 (1976)), it also prohibits
        “deliberate indifference to serious medical needs of prisoners.” Id.
        “Federal and state governments [ ] have a constitutional obligation
        to provide minimally adequate medical care to those whom they
        are punishing by incarceration.” Hoffer v. Sec’y, Fla. Dep’t of Corr.,
        973 F.3d 1263, 1270 (11th Cir. 2020) (quoting Harris v. Thigpen, 941
        F.2d 1495, 1504 (11th Cir. 1991)). Deliberate indifference to a
        prisoner’s serious medical needs is a violation of the Eighth
        Amendment. Estelle, 429 U.S. at 104. Deliberate indifference,
        however, is a “steep hill” for a plaintiff to climb. Hoffer, 973 F.3d at
        1272.
               Demonstrating deliberate indifference requires both an
        objective and subjective showing. Id. at 1270 (citing Farrow v. West,
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        20-10150                 Opinion of the Court                               13

        320 F.3d 1235, 1243 (11th Cir. 2003)). A plaintiff must show that (1)
        he suffered from an “objectively serious medical need” and (2) a
        prison official acted with subjective deliberate indifference to that
        medical need. Id.; see also Harper v. Lawrence Cnty., 592 F.3d 1227,
        1234 (11th Cir. 2010); Goebert v. Lee Cnty., 510 F.3d 1312, 1326
        (11th Cir. 2007). As to step one (the objective component), a
        medical need that is objectively serious “is one that has been
        diagnosed by a physician as mandating treatment or one that is so
        obvious that even a lay person would easily recognize the necessity
        for a doctor’s attention.” Goebert, 510 F.3d at 1326. As to step two
        (the subjective component), a plaintiff must establish that the
        defendant (1) had subjective knowledge of a risk of serious harm,
        (2) disregarded that risk, and (3) acted with more than gross
        negligence. Wade v. McDade, 67 F.4th 1363, 1366 (11th Cir. 2023). 2
               Applying this framework to each of the defendants here, we
        conclude that there are genuine disputes of material fact as to
        whether Drs. Ferrell, Lewis, and Marler were deliberately
        indifferent to Johnson’s serious medical needs. The district court
        erred in granting summary judgment.

        2
              Our cases say both that the standard is “more than mere negligence”
              and that it is “more than gross negligence.” Compare, e.g., McElligott v.
              Foley, 182 F.3d 1248, 1255 (11th Cir. 1999), with Townsend v. Jefferson
              Cty., 601 F.3d 1152, 1158 (11th Cir. 2010). Because there are issues of
              fact even under the “more than gross negligence” standard, we use
              that formulation here. See Brooks v. Miller, -- F4th --, 2023 WL 5355022
              at *12 n.4 (11th Cir. Aug. 22, 2023).
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        14                    Opinion of the Court               20-10150

                                         III

                We begin by acknowledging that the district court correctly
        found that the objective showing of deliberate indifference is
        satisfied with respect to each doctor. As this Circuit (and many
        others) have found—and as no party currently disputes—an HCV
        diagnosis is an objectively serious medical need. Hoffer, 973 F.3d at
        1270. So, we move to the three-step subjective inquiry, considering
        each doctor individually.

                      A.     Dr. Ferrell
               Dr. Ferrell was responsible for Johnson’s medical care
        during the twenty-six months he served at Ware State Prison.
        There is no dispute that Dr. Ferrell knew the risk of serious harm
        to Johnson given his HCV diagnosis, satisfying the first prong of
        the subjective inquiry. The dispute arises as to prongs two and
        three: whether Dr. Ferrell acted with more than gross negligence
        in disregarding that risk.
               The primary issue here is Dr. Ferrell’s decision not to
        administer the HCV treatment to Johnson notwithstanding
        Dr. Chaudhary’s prescription. The effect of that decision turns on
        whether the prescription was medically necessary. Johnson relies
        on Ancata v. Prison Health Servs., Inc., 769 F.2d 700, 704 (11th Cir.
        1985), in which this Circuit held that, “if necessary medical
        treatment has been delayed for non-medical reasons, a case of
        deliberate indifference has been made out.” Id. But cf. Youmans v.
        Gagnon, 626 F.3d 557, 564 (11th Cir. 2010) (holding that delaying
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        20-10150               Opinion of the Court                       15

        treatment for non-bleeding cuts and bruises was excusable because
        police needed to book the plaintiff into prison). While Dr.
        Chaudhary asserted that he prescribed Johnson’s HCV treatment
        based on Johnson’s litigiousness, his own medical advocacy, and
        out of an abundance of caution, Johnson correctly notes that these
        justifications were         only provided post-lawsuit.           No
        contemporaneous treatment documents or notes by Dr.
        Chaudhary reflect these justifications. And, even if these
        justifications are true, they do not necessarily negate a conclusion
        of medical necessity.
                For his part, Johnson successfully rebuts the notion that Dr.
        Chaudhary’s prescription was not medically necessary. He was
        sent to Dr. Chaudhary specifically for the purpose of determining
        whether he needed HCV treatment. At that time Johnson’s liver
        biopsy showed grade 2 inflammation, which indicated his disease
        was progressing. There is sufficient evidence in the record to
        conclude that Dr. Chaudhary’s prescription was both valid and
        medically necessary. Johnson also points out that Dr. Ferrell
        himself continuously confirmed to Johnson that he would receive
        treatment per Dr. Chaudhary’s prescription.
                There are genuine disputes of material fact as to whether Dr.
        Ferrell’s reasons for delaying treatment were non-medical or even
        pretextual. First, Dr. Ferrell claims he delayed administration of
        treatment due to Johnson’s temporary relocation to another
        prison, which Dr. Ferrell suggests could have disrupted the
        delivery of the medication. That is not necessarily true. The
        prescription (once Johnson finally received it) was easily
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        16                     Opinion of the Court                 20-10150

        transferred to another prison during a short-term stay. Second,
        there is also a factual dispute about Dr. Ferrell’s next claim, that the
        delay in the treatment administration was due to Johnson’s hernia
        surgery. The record reveals that, following his hernia surgery on
        October 1, 2013, Johnson returned to Ware just eight days later,
        did not spend any time in the recovery unit, and took nothing more
        than Tylenol to manage his pain. It strains credulity to believe that
        Johnson’s hernia surgery prevented him from receiving treatment
        for eight months.
               Dr. Ferrell relies on Hoffer, 973 F.3d at 1268, to argue that
        the delay does not amount to deliberate indifference. Hoffer is
        inapplicable here. That case confronted whether the Hepatitis-C
        treatment policy of the Florida Department of Corrections violated
        the Eighth Amendment per se. This Circuit held that the policy—
        which required the Department of Corrections to monitor inmates
        with Stage 0 or Stage 1 HCV, rather than treat them with
        medication—did not amount to deliberate indifference. The facts
        here are well outside the bounds of Hoffer: Johnson had a valid,
        outstanding prescription for HCV treatment, which he was denied.
        If the question were simply whether the GDC’s HCV treatment
        policy constituted a violation of the Eighth Amendment, Hoffer
        would control. But that is not the question presented here.
               The district court also concluded that Dr. Chaudhary’s
        prescription was not valid because he never completed the pre-
        therapy checklist required for treatment. Johnson argues that the
        prescription itself was valid and it was Dr. Ferrell’s delay that
        prevented the checklist from being completed. Johnson contends
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        20-10150               Opinion of the Court                        17

        that this failure does not nullify the prescription, but is more
        evidence of improper delay in treatment. This, like those
        mentioned above, is a dispute of material fact. The district court
        erred in making inferences in favor of Dr. Ferrell. If Johnson’s
        account of his treatment (or lack thereof) under Dr. Ferrell is true,
        a jury could find that the doctor’s actions amounted to deliberate
        indifference by delaying and declining to administer Johnson’s
        valid, outstanding HCV prescription without a valid justification.

                      B. Dr. Lewis
              There are genuine disputes of material fact with respect to
        Dr. Lewis’s conduct as well. The district court granted summary
        judgment on the ground that Johnson failed to show that Dr. Lewis
        had subjective knowledge of his HCV. But after months without
        treatment, Johnson submitted a grievance complaint detailing his
        condition and lack of treatment. The denial of Johnson’s grievance
        bears Dr. Lewis’s signature—a fact from which a jury could
        reasonably infer that she had knowledge of the contents of the
        form. See Gordon v. Schilling, 937 F.3d 348, 358 (4th Cir. 2019)
        (review and denial of prisoner’s grievance appeals by director was
        evidence sufficient to establish a genuine issue of fact that director
        had knowledge of prisoner’s HCV condition); United States v.
        Gaines, 690 F.2d 849, 855 (11th Cir. 1982) (holding that a jury could
        permissibly infer that an illiterate taxpayer’s signature on his tax
        return was evidence that he knew of the false contents of the tax
        return). Despite her signature appearing on the denial form, Dr.
        Lewis swore in her affidavit that she had no actual knowledge of
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        18                     Opinion of the Court               20-10150

        Johnson’s HCV. She avers that it is her regular practice to have staff
        review grievance forms, and her signature appears on the form
        simply by virtue of her role as the Statewide Medical Director.
               Perhaps so. But, as Johnson points out, Dr. Lewis’s say-so of
        having no actual knowledge of Johnson’s condition
        notwithstanding her own signature on the grievance denial form
        turns entirely on her credibility. Credibility determinations are
        within the purview of the jury, not the district court. See United
        States v. Grushko, 50 F.4th 1, 11 (11th Cir. 2022). There exists a
        dispute of material fact as to whether Dr. Lewis actually or only by
        delegation concluded that “medical personnel handled [Johnson’s
        HCV] case appropriately.” The district court improperly credited
        Dr. Lewis’s testimony that she had no knowledge of Johnson’s
        HCV while ignoring the circumstantial evidence from which a jury
        could conclude that she did.

                      C. Dr. Marler
               Johnson takes issue with three delays in treatment while
        under Dr. Marler’s care: the nearly two-year delay before
        performing a non-invasive FibroSure test instead of administering
        the liver biopsy Dr. Chaudhary had suggested; the two-month
        delay between Johnson’s Stage 4 FibroSure test result and the
        ultrasound confirmation results; and a four-month delay between
        the ultrasound and Johnson leaving Dr. Marler’s care in November
        2017 without having received any treatment. There are genuine
        disputes of material fact regarding the delay at each stage. We take
        each in turn.
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        20-10150               Opinion of the Court                      19

               First, Johnson argues that Dr. Marler ignored Dr.
        Chaudhary’s recommendation for a liver biopsy. In fact,
        Dr. Chaudhary’s notes reveal something less than a
        recommendation per se; he notes that a repeat liver biopsy should
        be “considered” in one year’s time. Instead of conducting a liver
        biopsy, Dr. Marler conducted routine check-ups, none of which,
        according to Marler, suggested Johnson’s condition was rapidly
        progressing. Nonetheless, Dr. Marler admits that a biopsy is the
        most accurate measure of liver disease yet chose not to perform
        one, despite the fact that Johnson’s ALT and AST scores were
        outside of the normal ranges from the moment he entered
        Dr. Marler’s care. And, as Johnson points out, there is no evidence
        that Dr. Marler’s decision not to perform a biopsy was based on his
        independent professional judgment. A jury could reasonably
        conclude that Dr. Marler’s failure to conduct the biopsy, knowing
        full well the potential risk and that Johnson had elevated markers,
        amounts to something more than gross negligence.
               The second alleged episodic delay in treatment arose on
        June 11, 2017, when Johnson received the FibroSure test and his
        results indicated severe progression of his HCV—F4 liver cirrhosis.
        After receiving these results, Johnson contends that Dr. Marler did
        nothing. Dr. Marler counters that he scheduled an ultrasound to
        confirm the results of the FibroSure test. But, there is no evidence
        that Dr. Marler did anything at all for 30 days to either pursue or
        rule out the need for treatment until he began a pre-therapy
        checklist on July 11, 2017. Drawing all inferences in favor of
        Johnson, Dr. Marler received Johnson’s FibroSure test results
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        20                     Opinion of the Court                20-10150

        indicating sever liver cirrhosis and did nothing for nearly a month.
        A jury could very well conclude that his failure to promptly treat
        amounted to more than gross negligence.
               Finally, on August 2, 2017, Johnson received the liver
        ultrasound that Dr. Marler scheduled. The results neither dispelled
        nor confirmed liver cirrhosis. At that point Dr. Marler admitted
        that “the degree of [Johnson’s] liver cirrhosis was still unclear.” And
        yet, there is evidence indicating Dr. Marler continued to do
        nothing. Johnson was abruptly transferred out of Dr. Marler’s care
        to a different CoreCivic prison on November 2, 2017. Though Dr.
        Marler claims he submitted Johnson’s case for treatment at some
        point (but could not provide a date or any documentation of such
        a referral), Johnson never received HCV treatment while under his
        care. A jury could well conclude that the lack of treatment Johnson
        received while under Dr. Marler’s care reflects more than gross
        negligence.

                                             ***
               The bar to proving an Eighth Amendment deliberate-
        indifference claim is certainly high, but it is not insurmountable.
        Johnson has raised a number of factual disputes regarding the
        denial of his HCV treatment for over eight years. These disputes
        are sufficiently material to be decided by a jury.

                                             IV
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        20-10150               Opinion of the Court                      21

               Johnson appeals the district court’s decision to deny his
        motion to amend the complaint. “We generally review the denial
        of a motion to amend a complaint for an abuse of discretion.”
        Williams v. Bd. of Regents of Univ. Sys. of Ga., 477 F.3d 1282, 1291
        (11th Cir. 2007) (citations omitted). Abuse of discretion is an
        extremely limited and highly deferential standard of review. It
        allows for a “zone of choice within which” the district court “may
        go either way.” United States v. Frazier, 387 F.3d 1244, 1259 (11th
        Cir. 2004) (quoting Kern v. TXO Prod. Corp., 738 F.2d 968, 971 (8th
        Cir. 1984)).
               Johnson, proceeding pro se, filed this case on October 12,
        2016. His initial complaint raised § 1983 and ADA claims and
        named numerous defendants including Drs. Ferrell, Lewis, and
        Marler. On October 13, 2017, Johnson moved to amend his
        complaint to add several new defendants and allege new facts.
        Then, on December 22, 2017, before the magistrate judge had
        ruled on Johnson’s motion to amend, an attorney named McNeill
        Stokes entered an appearance on Johnson’s behalf and moved for a
        30-day extension to respond to any outstanding motions and file a
        restated complaint. The magistrate judge granted Stokes’s motion
        for an extension and allowed him to file a “restated complaint.”
        Accordingly, she denied Johnson’s motion to amend as moot.
               On January 8, 2018, however, Stokes filed a motion to
        withdraw as Johnson’s attorney because Johnson declined to sign a
        representation agreement. That motion was granted on January 9,
        2018. Johnson was not served with the denial of his motion to
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        22                     Opinion of the Court               20-10150

        amend because, at the time of the denial, Stokes was still the
        attorney of record.
                Johnson alleges that the court abused its discretion by
        denying as moot his motion to amend the complaint and, further,
        that it violated Fed. R. Civ. P. 77(d)(1) because it never served
        Johnson with a copy of the order, instead serving it on Stokes.
        Specifically, Johnson contends that his motion could not have been
        mooted by a legal filing from Stokes, who was neither a party nor
        counsel to anyone in the proceeding.
                There is no doubt that reconsidering Johnson’s motion to
        amend sua sponte might have been the more prudent course of
        action for a pro se plaintiff once Stokes withdrew as counsel. But,
        that is not the standard for determining whether the district court
        abused its discretion. And, while courts afford pro se plaintiffs some
        liberties not enjoyed by members of the bar, construing the abuse
        of discretion standard more liberally is not one of them. The
        magistrate judge did not abuse his discretion by denying the
        motion as moot nor by serving Stokes rather than Johnson with the
        order, as Stokes was in fact the attorney of record at the time of the
        denial. That Johnson had not yet signed a representation
        agreement -- a fact not known by the district court -- does not mean
        that an attorney-client relationship had not formed or that Stokes
        acted in bad faith by entering an appearance on Johnson’s behalf at
        that time. Absent evidence that Stokes fraudulently represented
        that he was Johnson’s counsel, the district court’s failure to sua
        sponte reconsider the motion to amend and to serve Johnson with
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        20-10150               Opinion of the Court                       23

        a copy of its order do not amount to an abuse of the district court’s
        considerable discretion.

                                             V

               We reverse the district court’s grant of summary judgment
        as to Defendant-Appellees Ferrell, Lewis, and Marler and remand
        this case for further proceedings. We affirm the district court’s
        denial of Johnson’s motion to amend the complaint.

                   AFFIRMED IN PART AND REVERSED IN PART.