Court Opinion

ID: 6112138
Source: CourtListenerOpinion
Date Created: 2022-01-24 21:02:55.416706+00
Date Added: 2024-06-11T08:54:22.152312
License: Public Domain

Case: 21-1524   Document: 51     Page: 1   Filed: 01/05/2022

   United States Court of Appeals
       for the Federal Circuit
                 ______________________

  HEATHER WRIGHT, AS MOTHER AND NATURAL
      GUARDIAN OF MINOR CHILD, B.W.,
              Petitioner-Appellee

                            v.

       SECRETARY OF HEALTH AND HUMAN
                   SERVICES,
               Respondent-Appellant
              ______________________

                        2021-1524

                 ______________________

     Appeal from the United States Court of Federal Claims
 in No. 1:16-vv-00498-EGB, Senior Judge Eric G. Bruggink.
                 ______________________

                Decided: January 5, 2022
                 ______________________
Case: 21-1524    Document: 51      Page: 2    Filed: 01/05/2022

 2                                             WRIGHT   v. HHS

    MICHAEL P. MILMOE, Law Offices of Leah V. Durant,
 PLLC, Washington, DC, argued for petitioner-appellee.

     TRACI PATTON, Torts Branch, Civil Division, United
 States Department of Justice, Washington, DC, argued for
 respondent-appellant. Also represented by BRIAN M.
 BOYNTON, C. SALVATORE D'ALESSIO, HEATHER LYNN
 PEARLMAN.
                  ______________________

     Before PROST, TARANTO, and HUGHES, Circuit Judges.
 HUGHES, Circuit Judge.
     The son, B.W., of Petitioner-Appellee Heather Wright
 experienced immune thrombocytopenic purpura after re-
 ceiving his measles, mumps, and rubella vaccine. Later
 blood tests showed his condition had resolved. More than
 six months after he was first diagnosed, B.W. presented
 with bruising, a possible symptom of immune thrombocy-
 topenic purpura, but blood tests showed the condition had
 not recurred. The Court of Federal Claims held that those
 blood tests, occurring more than six months after his initial
 diagnosis, were “residual effects” of B.W.’s vaccine injury
 that satisfied the severity requirement of 42 U.S.C.
 § 300aa-11(c)(1)(D). We disagree. A residual effect must be
 a change within the patient that is caused by the vaccine
 injury. Because B.W.’s later bruising was not caused by his
 vaccine injury, and his tests did not reveal, constitute, or
 cause any somatic change, we reverse the Court of Federal
 Claims’s decision.
                        BACKGROUND
                              A
     In 1986, Congress established the National Vaccine
 Program within the Department of Health and Human
 Services “to achieve optimal prevention of human infec-
 tious diseases through immunization and to achieve
Case: 21-1524      Document: 51      Page: 3    Filed: 01/05/2022

 WRIGHT   v. HHS                                              3

 optimal prevention against adverse reactions to vaccines.”
 42 U.S.C. § 300aa-1. With the same statute (the “Vaccine
 Act”), Congress also established the National Vaccine In-
 jury Compensation Program, “under which compensation
 may be paid for a vaccine-related injury or death.” Id.
 § 300aa-10(a). A petitioner seeking compensation must es-
 tablish by a preponderance of the evidence that the injury
 or death was caused by a vaccine. See id. §§ 300aa-
 11(c)(1)(C), -13(a)(1). The petitioner may establish causa-
 tion in two ways. First, the petitioner may prove that the
 injury is one listed in the Vaccine Injury Table, 42 U.S.C.
 § 300aa-14(a); 42 C.F.R. § 100.3(a) (2020), and occurred
 within the time provided within the Table, establishing a
 presumption of causation. See Capizzano v. Sec’y of Health
 & Hum. Servs., 440 F.3d 1317, 1319–20 (Fed. Cir. 2006).
 Alternatively, for injuries not listed in the Vaccine Injury
 Table, the petitioner may prove causation in fact. Id. at
 1320 (citing 42 U.S.C. § 300aa-13(a)(1), -11(c)(1)(C)(ii)(I)).
 The causation-in-fact inquiry is governed by traditional
 principles of tort law described in the Second Restatement
 of Torts. Shyface v. Sec’y of Health & Hum. Servs., 165 F.3d
 1344, 1351–52 (Fed. Cir. 1999).
     Compensation is not available for minor injuries,
 whether on or off the Table. Instead, a showing of severity
 is required. As originally enacted, 42 U.S.C. § 300aa-
 11(c)(1)(D) required that a petition for compensation con-
 tain
     (1) . . . an affidavit, and supporting documentation,
     demonstrating that the person who suffered such
     injury or who died . . .
          (D)(i) suffered the residual effects or com-
          plications of such illness, disability, injury,
          or condition for more than 1 year after the
          administration of the vaccine, (ii) incurred
          unreimbursable expenses due in whole or
          in part to such illness, disability, injury, or
Case: 21-1524     Document: 51      Page: 4     Filed: 01/05/2022

 4                                                WRIGHT   v. HHS

         condition in an amount greater than
         $1,000, or (iii) died from the administration
         of the vaccine.
 National Childhood Vaccine Injury Act of 1986, Pub. L.
 No. 99–660, § 2111, 100 Stat. 3743, 3760–61. (1986). A
 1987 amendment shortened “1 year” to “6 months” and
 combined subsections (i) and (ii), allowing compensation
 with a showing of six months of residual effects and $1,000
 in unreimbursable expenses. Vaccine Compensation
 Amendments of 1987, Pub. L. No. 100–203 § 4304(b)(2),
 101 Stat. 1330, 1330-223 to -224 (1987). The legislative his-
 tory explains that the 1987 amendment
     limits compensation program to cases in which a
     person dies from the result of vaccine or in which a
     person incurs unreimbursable medical expenses of
     more than $1,000 and suffers ongoing disabilities
     for at least six months. This subsection eliminates
     the Act’s provision of eligibility for persons who in-
     cur expenses in excess of $1,000 but do not suffer
     ongoing disabilities. The effect of this provision is to
     limit the availability of the compensation system to
     those individuals who are seriously injured from
     taking a vaccine.
 H.R. Rep. No. 100-391, pt. 1, at 699 (1987). A 1998 amend-
 ment eliminated the $1,000 requirement altogether. Vac-
 cine Injury Compensation Program Modification Act, Pub.
 L. No. 105-277 § 1502, 112 Stat. 2681, 2681-741 (1998). To-
 day, the petitioner must show that the injured person
     (D)(i) suffered the residual effects or complications
     of such illness, disability, 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 illness, disability, in-
     jury, or condition from the vaccine which resulted
     in inpatient hospitalization and surgical interven-
     tion.
Case: 21-1524      Document: 51    Page: 5    Filed: 01/05/2022

 WRIGHT   v. HHS                                            5

 42 U.S.C. § 300aa-11(c)(1)(D).
                              B
     Thrombocytopenic purpura is included in the Vaccine
 Injury Table for the measles, mumps, and rubella (MMR)
 vaccine. 42 C.F.R. § 100.3(a) (2015). At the time this peti-
 tion was filed, thrombocytopenic purpura was defined as “a
 serum platelet count[ 1 ] less than 50,000/mm3.” 2 Id. at
 § 100.3(b)(8). A normal platelet count is between 150,000

 1   Platelet counts reveal “the number of platelets (throm-
 bocytes) per cubic milli[meter] of blood.” Crabbe v. Sec’y of
 Health & Hum. Servs., No. 10-762V, 2011 WL 4436724, at
 *2 n.9 (Fed. Cl. Spec. Mstr. Aug. 26, 2011) (quoting Kath-
 leen D. Pagana & Timothy J. Pagana, Mosby’s Manual of
 Diagnostic and Laboratory Tests 416 (4th ed. 2010)).
 2   “Thrombocytopenia” is defined as a platelet count less
 than 150,000/mm3. National Vaccine Injury Compensation
 Program: Revisions and Additions to the Vaccine Injury
 Table—II, 60 Fed. Reg. 56,289, 56,295 (Nov. 8, 1995). “Pur-
 pura” refers to a pattern of bleeding under the skin which
 is “generally only seen when the platelet counts are less
 than 50,000/mm3,” id., although such patterns were not
 part of the definition of thrombocytopenic purpura in the
 Vaccine Injury Table at the time this claim was filed, 42
 C.F.R. § 100.3(b)(8) (2015).
     Today, thrombocytopenic purpura is defined in the Ta-
 ble “by the presence of clinical manifestations, such as pe-
 techiae, significant bruising, or spontaneous bleeding, and
 by a serum platelet count less than 50,000/mm3 with nor-
 mal red and white blood cell indices.” 42 C.F.R.
 § 100.3(c)(7) (2020). The International Working Group on
 ITP uses a platelet count of less than or equal to
 100,000/mm3 for diagnosis. Appx33 n.3.
Case: 21-1524    Document: 51     Page: 6   Filed: 01/05/2022

 6                                            WRIGHT   v. HHS

 and 400,000/mm3. Crabbe v. Sec’y of Health & Hum. Servs.,
 No. 10-762V, 2011 WL 4436724, at *2 n.20 (Fed. Cl. Spec.
 Mstr. Aug. 26, 2011) (citing Kathleen D. Pagana & Timothy
 J. Pagana, Mosby’s Manual of Diagnostic and Laboratory
 Tests 416 (4th ed. 2010)). Thrombocytopenic purpura pro-
 duces bruising as well as more unusual patterns of bleed-
 ing under the skin called petechiae and purpura. See
 National Vaccine Injury Compensation Program: Revisions
 and Additions to the Vaccine Injury Table—II, 60 Fed. Reg.
 56,289, 56,295 (Nov. 8, 1995). As the Secretary recognized
 when adding it to the Table, thrombocytopenic purpura is
 rarely chronic, i.e., lasting more than 6 months, and
 chronic cases are thought to be the result of an autoim-
 mune disorder rather than viral vaccination or viral infec-
 tion. Id.
                             C
     B.W. was a two-year-old in good health. At his well-
 child visit on March 28, 2014, B.W. received the MMR vac-
 cine. About two weeks later, B.W. presented to an emer-
 gency room with bruises on his forehead, abdomen, and all
 four extremities. B.W.’s platelet count was only
 43,000/mm3. He was diagnosed with thrombocytopenia and
 discharged. The following day, B.W. arrived at Children’s
 Healthcare of Atlanta, where his platelet count was found
 to be 68,000/mm3. His treating physicians diagnosed B.W.
 with “thrombocytopenia likely secondary to acute ITP.” 3
 Appx4.

 3    ITP stands for immune thrombocytopenic purpura or
 immune thrombocytopenia. “Immune” refers to the cause
 of the thrombocytopenia and distinguishes thrombocytope-
 nia associated with anti-platelet antibodies, which may be
 caused by viral infections and vaccinations, from other
 forms of thrombocytopenia, such as heparin-induced
 thrombocytopenia or congenital thrombocytopenia. See
Case: 21-1524      Document: 51    Page: 7    Filed: 01/05/2022

 WRIGHT   v. HHS                                            7

     Over the following weeks, B.W. saw various pediatri-
 cians for frequent blood tests. His platelet count fluctuated
 between 68,000 and 180,000/mm3. B.W.’s hematologists
 concluded that he had thrombocytopenic purpura resulting
 from his MMR vaccination, but noted that his thrombocy-
 topenia was “not severe at this time” and recommended fol-
 low-up visits “every 1–2 months until resolution.” Appx4.
     On July 8, 2014—less than three months after onset of
 his thrombocytopenic purpura—B.W.’s pediatrician or-
 dered a platelet count, which came back normal. The pedi-
 atrician concluded that B.W.’s thrombocytopenic purpura
 had “resolved.” Appx4.
      On several occasions in the following two years, B.W.
 returned to his pediatrician with bruising and had his
 platelet count tested. Each time he was seen, his platelet
 count was well above 50,000/mm3 and within the normal
 range. B.W. was seen for bruising and headaches; his plate-
 let count was 312,000/mm3. He was seen for bruising on his
 shins and abdomen; his platelet count was 381,000/mm3.
 He was seen for bruising on his back and extremities, as
 well as petechiae on his mid and lower back; his platelet
 count was 289,000/mm3. He was seen again for bruising;
 his platelet count was 318,000/mm3.
                              D
     Ms. Wright filed a petition for compensation alleging
 that B.W.’s MMR vaccine caused thrombocytopenic pur-
 pura. The Secretary filed a Motion to Dismiss, arguing that
 Ms. Wright could not meet the “severity requirement” of 42

 generally 42 C.F.R. § 100.3(b)(7); National Vaccine Injury
 Compensation Program, 60 Fed. Reg. at 56,295; Thrombo-
 cytopenia, Dorland’s Illustrated Medical Dictionary 1892
 (33d ed. 2020); Douglas B. Cines et al., Congenital and Ac-
 quired Thrombocytopenia, 2004 Hematology 390.
Case: 21-1524    Document: 51      Page: 8    Filed: 01/05/2022

 8                                             WRIGHT   v. HHS

 U.S.C. § 300aa-11(c)(1)(D), given that B.W.’s thrombocyto-
 penic purpura had resolved less than six months after he
 got the vaccine. The special master dismissed the petition
 for failure to meet the severity requirement. The special
 master held that “testing for a possible recurrence is not a
 ‘residual effect’ within the meaning of the statute.” Wright
 v. Sec’y of Health & Hum. Servs., No. 16-498V, 2019 WL
 1061472, at *11 (Fed. Cl. Spec. Mstr. Jan. 18, 2019) (Spe-
 cial Master Decision) (quoting Crabbe, 2011 WL 4436724,
 at *5).
      Ms. Wright filed a motion for review of the Special Mas-
 ter Decision by the Court of Federal Claims. The court
 ruled that the special master erred as a matter of law in
 holding that there was no residual effect of B.W.’s throm-
 bocytopenic purpura. Wright v. Sec’y of Health & Hum.
 Servs., 146 Fed. Cl. 608, 615 (2019) (Court of Federal
 Claims Decision). The court reasoned that “ordering plate-
 let counts when a patient with a history of ITP is presented
 with bruising” was “within the doctor’s reasonable stand-
 ard of care” and that B.W.’s testing was “causally connected
 to the vaccine injury” because “it [wa]s unlikely B.W. would
 have undergone continued platelet testing if it were not for
 his history with ITP.” Id. at 614 & n.8. The court held that
     testing for a condition that could return ought to be
     compensated under the Vaccine Act when that test-
     ing is causally connected to the underlying vaccine
     injury and triggered by subsequent symptoms of
     the conditions. The fact that those tests did not re-
     veal the presence of ITP is not controlling. The
     tests became necessary when later symptoms trig-
     gered concern because of the earlier injury; they
     were not mere monitoring.
 Id. The court remanded to the special master, who awarded
 damages. Wright v. Sec’y of Health & Hum. Servs., No. 16-
 498V, 2020 WL 6281782, at *1, *3 (Fed. Cl. Spec. Mstr.
Case: 21-1524      Document: 51     Page: 9     Filed: 01/05/2022

 WRIGHT   v. HHS                                               9

 Sept. 25, 2020). The Secretary timely appealed. We have
 jurisdiction pursuant to 42 U.S.C. § 300aa-12(f).
                          DISCUSSION
      The facts of this case are not disputed. The construction
 of “residual effects” in the Vaccine Act is a question of law,
 which we review de novo. Flowers v. Sec’y of Health &
 Hum. Servs., 49 F.3d 1558, 1559 (Fed. Cir. 1995).
                                A
     The “starting point” in statutory construction “is the
 language of the statute”—not a single sentence or word of
 the statute, but rather the “provisions of the whole law,” its
 object, and its policy. Dole v. United Steelworkers of Am.,
 494 U.S. 26, 35 (1990). The term “residual effects,” read
 with the entirety of 42 U.S.C. § 300aa-11(c)(1)(D)(i), re-
 quires a change within the patient that is caused by the
 vaccine injury.
      The language “effect . . . of such illness, disability, in-
 jury, or condition” dictates that a residual effect must be
 caused by the vaccine injury. The Vaccine Compensation
 Program was intended as an alternative to the tort system.
 See Shalala v. Whitecotton, 514 U.S. 268, 269–70 (1995)
 (citing H.R. Rep. No. 99-908, at 3–7 (1986)) (explaining that
 the Act “establishes a scheme of recovery designed to work
 faster and with greater ease than the civil tort system”).
 Absent legislative history to the contrary, we have applied
 traditional principles of causation in tort law to the Vaccine
 Act. See Shyface v. Sec’y of Health & Hum. Servs., 165 F.3d
 1344, 1351–52 (Fed. Cir. 1999) (adopting the causation
 standard from the Second Restatement of Torts for pur-
 poses of proving causation for off-Table injuries under 42
 U.S.C. § 300aa-11(c)(1)(C)(ii)). Here, Congress has not spo-
 ken on the standard of causation, see H.R. Rep No. 99-908,
 at 15 (1986) (not addressing causation for purposes of the
 provision at the time of enactment); H.R. Rep. No. 100-391,
 pt. 1, at 699 (1987) (not addressing causation at the time of
Case: 21-1524    Document: 51      Page: 10    Filed: 01/05/2022

 10                                             WRIGHT   v. HHS

 amendment, when discussing the severity requirement).
 Thus, we follow the Second Restatement and the causation
 standards articulated for purposes of 42 U.S.C. § 300aa-
 11(c)(1)(C)(ii). 4 Under this approach, it is sufficient that
 the vaccine injury be both a but-for cause of the residual
 effect and a substantial factor in bringing about the resid-
 ual effect, even if it is not the predominant factor. Shyface,
 165 F.3d at 1352 (citing Restatement (Second) of Torts).
     Petitioner has not shown or argued in this case that
 B.W.’s bruising after six months was caused by thrombocy-
 topenic purpura. In fact, the later tests “did not reveal the
 presence of ITP.” Court of Federal Claims Decision at 614.
 So the bruising cannot itself be a “residual effect” under the
 severity requirement.
     The Court of Federal Claims concluded that B.W.’s
 testing was “triggered by” his prior history of thrombocyto-
 penic purpura and therefore “causally linked” to the condi-
 tion. Court of Federal Claims Decision at 613. It cited
 evidence of but-for causation. Id. at 614 n.8. But the court
 identified a separate cause, bruising and petechiae, and
 linked B.W.’s testing to his “presentation of symptoms of
 ITP.” Id. at 614. Neither the Court of Federal Claims nor
 the special master expressly applied a causation standard
 or considered both the thrombocytopenic purpura and the

 4    “Residual effects or complications” in the severity re-
 quirement bears similarity to “complication or sequela” in
 the Vaccine Injury Table, 42 C.F.R. § 100.3(b)(1), and the
 Secretary has defined a but-for causation standard for that
 language. 42 C.F.R. § 100.3(d)(3) (2020) (“Sequela means a
 condition or event which was actually caused by a condition
 listed in the Vaccine Injury Table.”). However, the Secre-
 tary specifically defined the word “sequela,” not “complica-
 tion,” and “sequela” does not appear in the severity
 requirement.
Case: 21-1524      Document: 51    Page: 11     Filed: 01/05/2022

 WRIGHT   v. HHS                                             11

 presentation of bruising after six months to determine
 whether the thrombocytopenic purpura was a “substantial
 factor” in bringing about the testing. But even if legally
 caused by his thrombocytopenic purpura, B.W.’s testing
 was not a “residual effect” for reasons discussed next.
      “Residual” suggests something remaining or left be-
 hind from a vaccine injury. See Parsley v. Sec’y of Health &
 Hum. Servs., No. 08-781V, 2011 WL 2463539, at *16 (Fed.
 Cl. Spec. Mstr. May 27, 2011) (“‘Residual’ is defined as ‘re-
 maining or left behind.’” (quoting Dorland’s Illustrated
 Medical Dictionary 1650 (31st ed. 2007))). An effect that is
 “residual” or “left behind” is one that never goes away or
 that recurs after the original illness. Because vaccine inju-
 ries are somatic conditions defined by their signs and
 symptoms within the patient, see 42 C.F.R. § 100.3(c), their
 residues are similarly defined.
     The words “suffered” and “complication,” used in asso-
 ciation with “residual effects” in § 300aa-11(c)(1)(D)(i), also
 suggest that Congress contemplated residual effects to be
 detrimental conditions within the patient, such as linger-
 ing or recurring signs and symptoms.
     “Suffered” suggests something detrimental, especially
 something painful. See Suffer, Webster’s Third New Inter-
 national Dictionary 2284 (1986) (“to be subjected to physi-
 cal or mental pain because of : endure with distress”). One
 does not naturally “suffer” from ongoing, minimally inva-
 sive monitoring or diagnostic testing, particularly when
 the underlying injury was found to have resolved.
     In the context of the Vaccine Injury Table, “complica-
 tion” is understood to have its medical meaning, “[a] mor-
 bid process or event occurring during a disease which is not
 an essential part of the disease, although it may result
 from it.” Abbott v. Sec’y of Dep’t of Health & Hum. Servs.,
 27 Fed. Cl. 792, 794 (1993) (citing Stedman’s Medical Dic-
 tionary 336 (25th ed. 1990), aff’d in pertinent part, re-
 manded in part, 19 F.3d 39 (Table) (Fed. Cir. 1994)); see
Case: 21-1524    Document: 51      Page: 12    Filed: 01/05/2022

 12                                             WRIGHT   v. HHS

 also Parsley v. Sec’y of Health & Hum. Servs., No. 08-781V,
 2011 WL 2463539, at *16 (Fed. Cl. Spec. Mstr. May 27,
 2011) (defining “complication” for purposes of the severity
 requirement as “‘disease or diseases concurrent with an-
 other disease’ or as ‘the concurrence of two or more diseases
 in the same patient’” (quoting Dorland’s Illustrated Medi-
 cal Dictionary 404 (31st ed. 2007))). These medical defini-
 tions characterize complications as “diseases” and “morbid
 processes.” Read together, “residual effects” and “complica-
 tions” appear to both refer to conditions within the patient,
 with “residual effects” focused on lingering signs, symp-
 toms, or sequelae characteristic of the course of the original
 vaccine injury, and “complications” encompassing condi-
 tions that may not be “essential part[s] of the disease” or
 may be outside the ordinary progression of the vaccine in-
 jury.
      Read in context, “residual effects” is focused on effects
 within the patient, particularly lingering signs and symp-
 toms of the original vaccine injury. B.W.’s testing did not
 fall into this category. The tests revealed B.W. had no lin-
 gering symptoms or recurrence of thrombocytopenic pur-
 pura. And although Petitioner contends that the testing
 itself was a “residual effect,” there has been no showing or
 argument that it was detrimental to B.W.’s health such
 that it might qualify under § 300aa-11(c)(1)(D)(i) as a “re-
 sidual effect” or a “complication” of thrombocytopenic pur-
 pura.
                               B
     The legislative history accords with this interpretation.
 See Flowers v. Sec’y of Dep’t of Health & Hum. Servs., 49
 F.3d 1558, 1560 (Fed. Cir. 1995) (“Our statutory interpre-
 tation begins with the language of the statute itself, which
 must ordinarily be regarded as conclusive absent a clearly
 expressed legislative intent to the contrary.” (citing Con-
 sumer Prod. Safety Comm’n v. GTE Sylvania, Inc., 447 U.S.
 102, 108 (1980))). The elimination of the $1,000
Case: 21-1524      Document: 51    Page: 13    Filed: 01/05/2022

 WRIGHT   v. HHS                                            13

 requirement as a standalone option under § 300aa-
 11(c)(1)(D) and the accompanying legislative history illus-
 trate Congress’s intent to require changes within the pa-
 tient.
      The 1987 amendment “eliminate[d] . . . eligibility for
 persons who incur expenses in excess of $1,000 but do not
 suffer ongoing disabilities” and are not “seriously injured.”
 H.R. Rep. No. 100-391, pt. 1, at 699 (1987) (emphases
 added). Injuries and disabilities are detrimental changes
 within the patient. Further, Congress contrasted “ongoing
 disabilities” with expenses in excess of $1,000. Unlike ongo-
 ing disabilities, expenses are decidedly external effects more
 clearly meant to encompass the detriments of ongoing mon-
 itoring. With its 1998 amendment, Congress wrote expenses
 out of the severity requirement altogether, indicating our
 analysis should focus on the vaccine injury and its medical
 consequences.
     By pairing “suffer” with “ongoing disability” and equat-
 ing that with being “seriously injured,” Congress further
 demonstrated that it intends the word “suffered” to require
 painful or otherwise detrimental effects. And like its use in
 the text of the statute, the repeated use of the word “suffer”
 in the 1987 report and the stated intent to limit compensa-
 tion to only those individuals who are “seriously injured
 from taking a vaccine,” H.R. Rep. No. 100-391, pt. 1, at 699
 (1987), show that the types of residual effects contemplated
 by the statute do not encompass relatively non-invasive
 testing.
      B.W.’s relatively non-invasive ongoing monitoring is
 neither an “ongoing disability” nor indicative that he “suf-
 fered” or was “seriously injured” within Congress’s in-
 tended meaning of the severity requirement. B.W. did not
 suffer ongoing disabilities from his vaccine and in fact was
 not shown to have suffered any lingering somatic effects at
 all after six months.
Case: 21-1524    Document: 51      Page: 14    Filed: 01/05/2022

 14                                             WRIGHT   v. HHS

                               C
     We do not disturb existing case law holding that a
 course of treatment lasting longer than six months can be
 a “residual effect.” See H.S. v. Sec’y of Health & Hum.
 Servs., No. 14-1057V, 2015 WL 1588366 (Fed. Cl. Spec.
 Mstr. Mar. 13, 2015) (holding that restriction on physical
 activity after a concussion, which was medically necessary
 to prevent further consequences, was a residual effect);
 Faup v. Sec’y of Health & Hum. Servs., No. 12-87V, 2015
 WL 443802 (Fed. Cl. Spec. Mstr. Jan. 13, 2015) (holding
 that an individual’s chronic arthritis was a residual effect
 even though it was well-controlled by medication). During
 a long course of treatment, the patient generally has some
 lingering condition such that symptoms will likely recur if
 the treatment were stopped. Otherwise, the long course of
 treatment would not be necessary.
     We do not decide today whether a course of testing or
 monitoring that is part of the management or treatment of
 a condition, necessary even in the absence of possible
 symptoms, could be a “residual effect.” In such a case, the
 monitoring may be considered part of treatment of a condi-
 tion that has not resolved, if the patient’s somatic condition
 increases the risk of recurrence. For example, if a patient
 were shown to have a chronic condition that does not ordi-
 narily resolve on its own within six months, and where
 some somatic change (e.g., a dormant infection or autoim-
 mune condition) underlies the chronic condition, then test-
 ing might be medically appropriate as part of the course of
 treatment even in the absence of recurring symptoms.
     We also do not decide whether diagnostic procedures
 that are more invasive, high-risk, or painful than the rou-
 tine blood draws of this case may be “residual effects” or
 “complications” even for a condition that has resolved. Such
 testing may be more in line with Congress’s intent to com-
 pensate those who “suffered” for more than six months. In
 addition, such procedures could cause somatic changes that
Case: 21-1524      Document: 51   Page: 15    Filed: 01/05/2022

 WRIGHT   v. HHS                                           15

 are “complications” within the meaning of 42 U.S.C.
 § 300aa-11(c)(1)(D)(i).
      Finally, although we focus here on medical effects, we
 do not intend to exclude psychological effects from the def-
 inition of “residual effects.” See Special Master Decision at
 *11 (citing Tauer v. Sec’y of Health & Hum. Servs., No. 08-
 703V, 2009 WL 2045676, at *1 (Fed. Cl. Spec. Mstr. June
 22, 2009) (decision on stipulation)).
                         CONCLUSION
     Because the Court of Federal Claims erred in holding
 that B.W.’s platelet count tests were residual effects within
 the meaning of the statute, we reverse the Court of Federal
 Claims Decision.
                         REVERSED
                            COSTS
 No Costs.