Joshua Horton v. Centurion of Tenn., LLC

JANE B. STRANCH, Circuit Judge. In December 2022, while in the custody of the Tennessee Department of Correction (TDOC), Joshua Horton developed a spinal infection that ultimately led to his paralysis. TDOC’s contract medical providers did not send Horton to the hospital when he became immobile and X-rays showed possible compression fractures, discitis/osteomyelitis, and/or malignancy in his spine. Despite his worsening condition, they provided him with pain medication only. Horton sued Dr. Richard P. Guerrant, III, Advanced Practice Registered Nurse Tommie June Hendrix Labonte (N.P. Hendrix Labonte), and Centurion of Tennessee, LLC (Centurion), the private company contracted to provide healthcare services to TDOC facilities. Horton brings 42 U.S.C. § 1983 claims of deliberate indifference to his serious medical needs in violation of the Eighth Amendment against Dr. Guerrant and N.P. Hendrix Labonte and of municipal liability against Centurion, and also raises medical claims against all Defendants under state law. The district court granted Defendants-Appellees summary judgment on Horton’s § 1983 claims and declined to exercise supplemental jurisdiction over the state law claims. We REVERSE IN PART, AFFIRM IN PART, VACATE IN PART, and REMAND for further proceedings.

I. BACKGROUND

Factual Background¹1. We draw our facts from the record before the district court.

A.

Horton entered TDOC custody on November 4, 2019, and was transferred to NWCX on January 5, 2020. At all times during Horton’s incarceration at NWCX, Centurion and its licensed healthcare professionals were contracted to provide healthcare services to Horton and other incarcerated individuals. People incarcerated at NWCX could request to be seen by a medical professional by submitting a sick call request (SCR) with a description of their medical issue. A sick call nurse would collect the SCRs, log them, and see the individual for evaluation, usually the next day. Nursing staff would screen the complaints, and when necessary, refer individuals to other providers for additional care.

During Horton’s medical treatment at NWCX, he was seen by Dr. Guerrant and Dr. Fowler, N.P. Hendrix Labonte, and Physician’s Assistant Amanda Collins (P.A. Collins). Only Defendants Dr. Guerrant and N.P. Hendrix Labonte are named parties to this suit.

In November 2020, Horton started having issues in the cervical and lumbar regions of his spine and reported periodic numbness in his arms and legs. He had cervical and lumbar spine X- rays that were reviewed on February 10, 2021, by Dr. Guerrant, who then diagnosed Horton with degenerative disc disease of the cervical and lumbar spine and prescribed a non-steroidal anti-inflammatory drug (NSAID).

Horton submitted another SCR on February 23, 2021, noting that he “[f]ell because his leg was numb;” he was seen by N.P. Hendrix Labonte, who documented Horton’s complaints, prescribed a steroid taper, ordered an EKG and lab tests, and referred him to Dr. Fowler. R. 97- 16, Pl.’s Resp. to Statement of Undisputed Material Facts, PageID 2546–47 ¶¶ 6–9 (alteration in original). A cervical X-ray showed prior cervical fusion at the C5–C6 vertebrae and degenerative osteoarthritis, and a subsequent MRI showed “multilevel degenerative disc disease with loss of disc height and disc desiccation” in the cervical section of Horton’s spine and otherwise noted “[n]o significant disc herniation central canal or foraminal stenosis” in his thoracic spine. R. 97-1, TDOC Med. R., PageID 2303. When Horton was then seen by a neurosurgeon in August, the neurosurgeon recommended physical therapy, anti-inflammatory medications, and a referral to a pain-management specialist for cervical facet injections. Horton was also provided with a mobility device called a rollator.

In September 2021, Horton submitted a SCR and was seen by N.P. Hendrix Labonte, who reviewed the neurosurgeon’s report and recommendation and requested a physical therapy consultation. Dr. Fowler requested a lumbar MRI, which was reviewed by Dr. Guerrant. In December, Horton reported no improvement in his condition and was walking with a cane. P.A. Collins prescribed a muscle relaxer, an antidepressant for neuropathic pain, and issued him a low bunk pass. N.P. Hendrix Labonte requested a referral to a pain management specialist for cervical facet injections in March 2022, and Horton received a transforaminal epidural steroid injection (ESI) in the cervical spine in April. On June 13, Horton again saw Dr. Guerrant, who documented Horton’s medical history, including that he was in physical therapy and received an ESI. At that time, Dr. Guerrant noted inconsistencies between Horton’s previous MRI findings and his presenting symptoms.

On July 6, Horton was involved in an accident while riding in a TDOC transport van. Horton later began reporting chest discomfort with breathing and ultimately received a second ESI in the cervical spine, more NSAIDS, and continued special accommodations. In September, Horton reported to P.A. Collins that the second ESI did not help with his pain, and Collins requested another ESI referral, which was rejected by TDOC Utilization Management. Horton submitted another SCR in October 2022, complaining that his back gave out, he could not move without spasms, and that pain medication and Icy Hot were not reducing the pain. Dr. Guerrant saw Horton on October 10, 2022, and noted that Horton presented “with complaints of symptoms involving his midback [in] mid thoracic to mid lumbar area,” pain and numbness with no new injury, and that Horton had previously had unsuccessful ESIs in his cervical spine. R. 97-1, PageID 2277. At this appointment, Dr. Guerrant told Horton that he would request a thoracic MRI and that he was concerned about Horton’s symptoms but needed more information. Regarding this MRI request, Dr. Guerrant wrote in his notes that because of Horton’s history of degenerative disease of the cervical spine, the MRI was needed to rule out “more cephalad injury.” R. 97-1, PageID 2277.

Dr. Guerrant’s MRI request was denied on October 18 by Utilization Management with the accompanying written explanation:

ATP-please clarify rationale for thoracic spine MRI in patient with known cervical disc disease without new deficits (pain and numbness noted in consult but not demonstrated in progress note). Please also provide documentation of contraindication to or failure of a trial of NSAIDS or acetaminophen for at least 3 weeks, failure of home exercises for at least 6 weeks, and failure of activity modification for at least 6 weeks. R. 90-2, Dr. Fowlkes Rep., PageID 1078, ¶ 41.b. Dr. Guerrant testified in his deposition that he interpreted this denial as Utilization Management recommending an alternative treatment plan of pain medication, home exercises, and activity modifications, and that because he believed these recommendations to be reasonable, he implemented them.

The day after this denial, on October 19, 2022, Horton submitted an SCR stating, “[n]eed something for back pain that I was seen for around the 10th it is starting to hurt when I breath[e].” R. 94-2, Ex. to Guerrant Dep., PageID 1977. Then, on October 24, Horton stated in another SCR, “I have put in sick calls on 19 Oct 22 and 23 Oct 22 [sic] and was not called for either! I am experiencing severe back pain and was seen the 10th. It is worse and causing more issues. I cannot take a full breath now without intense pain.” R. 94-2, PageID 1978. In response, P.A. Collins prescribed Horton pain medication and consulted with a physician.

On November 8, 2022, Horton submitted an SCR stating, “[b]ack pain is escalating badly. Can barely move now. This has been going on for over a month. I need to see a provider today please.” R. 97-1, PageID 2274. He was then seen by N.P. Hendrix Labonte, who conducted an evaluation, ordered a steroid taper, and requested a follow-up appointment. On November 11, a sick call nurse assessed Horton and found that he had decreased range of motion and weakness in his back. N.P. Hendrix Labonte then saw him on November 15, renewed his bottom bunk pass, and refilled his Icy Hot prescription. She also informed Horton that his CSI request had been denied and that Dr. Guerrant had ordered a thoracic X-ray and requested an MRI, presumably a reference to the MRI request in October that was denied. Horton then submitted SCRs on November 20 and 25, requesting a follow up with Dr. Guerrant because of “extreme pain” and his near inability to “walk or stand.” R. 97-1, PageID 2270.

Horton was again seen by N.P. Hendrix Labonte on November 30, and she noted in her assessment that Horton had “[s]evere midback pain,” “unstable gait,” diminished ability to hold arms in front of body, and muscle weakness in his upper and lower extremities and pain that interfered with his daily activities. R. 97-1, PageID 2297. Labonte discussed her exam with Dr. Guerrant, and together they developed a plan to submit a new request for a thoracic MRI. The second MRI request was approved on December 8, and the MRI was scheduled for December 21. Dr. Guerrant also ordered an abdominal X-ray and thoracic spine X-rays, which were performed on December 2, 2022. The radiologist report from the X-ray notes the results as “T8 and T9 vertebral body height loss” and “[c]omplete disc height loss at T8–T9” and concludes that “[c]omplete loss of disc height at T8–T9 [was] concerning for compression fractures, discitis/osteomyelitis, and/or malignancy, [and was] new since prior [X-ray].” R. 97-1, PageID 2256. Osteomyelitis is a vertebral infection that can cause death, infection, paralysis, and malignancy.

Horton submitted an SCR on December 5, 2022, stating “I need to go to ER immediatly [sic] because I can’t sit up or stand up. My back is getting worse every day. I need a wheelchair to take me where I need to go.” R. 97-1, PageID 2265. N.P. Hendrix Labonte was notified and wrote an order for an appointment so she could discuss his X-ray results with him. Horton submitted another SCR on December 7 stating “[f]ollow up with back pain. I need something to stop my weight from dropping further. I can’t walk or eat the pain is so bad.” R. 97-1, PageID 2263. Horton was evaluated by nursing staff on December 8, his vital signs were normal, and he did not have a fever, but throughout his thoracic area he had 10/10 pain, no relieving factors, numbness, and tingling. Horton was also unable to stand on his own and arrived at the clinic in a wheelchair. The nursing staff called Dr. Guerrant and read him Horton’s X-ray results, and Dr. Guerrant ordered pain medication. On December 9, Dr. Guerrant saw Horton and prescribed an NSAID and other pain medication.

Horton submitted an SCR on December 11, 2022, stating “Need to see Dr. Guerrant or ER, today. Over the weekend loss [sic] use of right leg and left leg is doing the same. Can’t walk and things are worsening.” R. 97-1, PageID 2260. Neither Dr. Guerrant nor N.P. Hendrix Labonte recall seeing this SCR. Horton was brought into the clinic on December 19, unable to move his legs and incontinent of urine. He was taken to the hospital and Dr. Guerrant was notified. A blood culture revealed that Horton had staphylococcus and antibiotics were administered. Horton was also diagnosed with vertebral osteomyelitis (a spinal infection), with the subsequent surrounding inflammation and adjacent epidural abscess causing a spinal cord injury at T8–T9 level, ultimately leaving Horton paralyzed.

B. Procedural Background

Horton filed a Complaint on November 6, 2023, raising claims under 42 U.S.C. § 1983 against Dr. Guerrant and N.P. Hendrix Labonte for deliberate indifference to his serious medical needs in violation of the Eighth Amendment. Horton also brought § 1983 municipal liability claims against Centurion, alleging that its policies or customs resulted in his constitutional injury. Horton also sued Centurion, TDOC, NWCX, Dr. Guerrant, and N.P. Hendrix Labonte for medical negligence under the Tennessee Health Care Liability Act. Dr. Guerrant, N.P. Hendrix Labonte, and Centurion filed motions for summary judgment, and the district court issued its Order deciding the summary judgment motions on June 4, 2025.²2. Before granting summary judgment in Defendants-Appellants’ favor, the district court dismissed Horton’s claims against Defendants TDOC and NWCX on sovereign immunity grounds. The court granted summary judgment to Dr. Guerrant, N.P. Hendrix Labonte, and Centurion on the § 1983 claims against them. And the court declined to exercise supplemental jurisdiction over Horton’s state medical negligence claims, dismissing them without prejudice. Horton timely appealed.

II. STANDARD OF REVIEW

This court reviews a district court’s summary judgment determination de novo. Montell v. Diversified Clinical Servs. Inc., 757 F.3d 497, 503 (6th Cir. 2014). Summary judgment is appropriate only if “there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). A fact is material if it “might affect the outcome of the suit under the governing law[,]” and a dispute about a material fact is genuine “if the evidence is such that a reasonable jury could return a verdict for the nonmoving party.” Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). At the summary judgment stage, we consider the evidence in the light most favorable to the non-moving party, drawing all reasonable inferences in that party’s favor. Chapman v. UAW Local 1005, 670 F.3d 677, 680 (6th Cir. 2012) (en banc). And where, as here, the parties filed cross-motions for summary judgment “the court must evaluate each party’s motion on its own merits, taking care in each instance to draw all reasonable inferences against the party whose motion is under consideration.” Taft Broad. Co. v. United States, 929 F.2d 240, 248 (6th Cir. 1991) (quoting Mingus Constructors, Inc. v. United States, 812 F.2d 1387, 1391 (Fed. Cir. 1987)).

III. ANALYSIS

Deliberate Indifference Claims Against Individual Defendants³3. Because Dr. Guerrant and N.P. Hendrix Labonte did not invoke qualified immunity in their summary judgment motion, they have forfeited this defense. See Cockrun v. Berrien County., 101 F.4th 416, 419–21 (6th Cir. 2024).

A.

To prevail on a cause of action under § 1983, a plaintiff must prove “(1) the deprivation of a right secured by the Constitution or laws of the United States (2) caused by a person acting under the color of state law.” ⁴4. As medical providers employed by the state to provide prison medical care, Dr. Guerrant and N.P. Hendrix Labonte qualify as state actors under § 1983 regardless of whether they are state employees or contractors. West v. Atkins, 487 U.S. 42, 55–56 (1988). Shadrick v. Hopkins County, 805 F.3d 724, 736 (6th Cir. 2015) (quoting Jones v. Muskegon County, 625 F.3d 935, 941 (6th Cir. 2010)). Prison medical staff can be held liable under the Eighth Amendment’s protection against cruel and unusual punishment for acting with deliberate indifference to an incarcerated individual’s serious medical need. Farmer v. Brennan, 511 U.S. 825, 834–35 (1994); see also Estelle v. Gamble, 429 U.S. 97, 104–05 (1976).

The deliberate indifference standard has both an objective and subjective component. Blackmore v. Kalamazoo County, 390 F.3d 890, 895 (6th Cir. 2004) (citing Farmer, 511 U.S. at 834). Objectively, Horton must show that he had a “‘sufficiently serious’ medical need.” Id. (quoting Farmer, 511 U.S. at 834). On the subjective component, Horton must show that the Defendants (1) subjectively perceived facts from which to infer substantial risk to Horton, (2) did in fact draw that inference, and (3) then disregarded that risk. Farmer, 511 U.S. at 837. The subjective prong standard is akin to criminal law recklessness. Id. at 836–37.

1. Objective Component

The Supreme Court in Farmer explained that showing a serious need for medical care under the objective component requires only that an inmate “show that he is incarcerated under conditions posing a substantial risk of serious harm.” 511 U.S. at 834. In Blackmore, we defined the objective component as “evidence of serious medical needs.” 390 F.3d at 896 (citation modified). Blackmore held that a medical need’s “seriousness” can be shown by either the medical need being “so obvious that even a lay person would easily recognize the necessity for a doctor’s attention,” or being “diagnosed by a physician as mandating treatment.” Id. (citation modified). Blackmore’s standard has been and remains supported by a significant line of Sixth Circuit cases, including our recent decision Griswold v. Trinity Health Mich., 175 F.4th 706, 711 (6th Cir. 2026). We thus follow our governing precedent in applying the Supreme Court’s objective standard from Farmer as we applied and explained it in Blackmore, 390 F.3d at 896–98.

Under Blackmore, when a medical need is obvious, the plaintiff need not place “verifying medical evidence in the record.” Id. at 898 (quoting Napier v. Madison County, 238 F.3d 739, 742 (6th Cir. 2001)). Rather, the “verifying medical evidence” requirement “is relevant to those claims involving minor maladies or non-obvious complaints of a serious need for medical care.” Id. In sum, the requirement does not apply “to medical care claims where facts show an obvious need for medical care that laymen would readily discern as requiring prompt medical attention by competent health care providers.” Id.

We have found the obviousness standard to be satisfied in circumstances mirroring this case—when a plaintiff: continuously fell to the ground, was unable to walk, complained about numbness and pain in the legs and back, and rated his pain as ten out of ten, Howell, 67 F.4th at 312; was admitted to the emergency room and stayed several days, Garretson v. City of Madison Heights, 407 F.3d 789, 797 (6th Cir. 2005); and had a spinal infection that caused his inability to move his legs, Adkins v. Morgan County, 798 F. App’x 858, 862 (6th Cir. 2020). Although Horton had previously complained about chronic back pain that resulted in differing diagnoses, his symptoms clearly changed in December 2022. At this point, he submitted SCRs stating that he was no longer able to sit, stand, walk or eat; he reported 10/10 pain specifically in the thoracic region of his back; an X-ray showed that he was at risk for a spinal infection; he lost the use of his legs and was incontinent of urine; and he was diagnosed with a spinal infection that led to his paralysis. Under our precedent, these facts clearly establish an obvious medical need, thus satisfying the objective component. See Howell, 67 F.4th at 312; Garretson, 407 F.3d at 797; Adkins, 798 F. App’x at 862.

And even if Horton had been required to place other or additional verifying medical evidence in the record to meet the objective component, he did so through the expert testimony of Dr. Johnny Bates. Dr. Bates testified in his deposition that Horton’s December 2 X-ray results “should have sent shivers up and down the spines of the providers, and an emergent MRI or CT scan should have been obtained.” R. 94-11, Bates Dep., PageID 2198. Dr. Bates also stated that Horton should have been sent to the hospital the day the X-ray results came back, and that if he had been sent to the hospital at any time between December 5 and 19, he would have avoided paralysis. See R. 90-8, Bates Dep., PageID 1368. It was, in Dr. Bates’s expert opinion, the “culmination of all of the documentation and poor examinations that [Horton] received” that led to Horton’s paralysis. Id. at PageID 1354. So, under either Blackmore analysis—demonstrating a medical need’s seriousness by its obviousness to a lay person or by its diagnosis by a physician— Horton has satisfied the objective prong. When analyzing the objective component, the district court applied Rhinehart v. Scutt, which held that “the objective component of an Eighth Amendment claim requires a showing of care ‘so grossly incompetent, inadequate, or excessive as to shock the conscience or to be intolerable to fundamental fairness.’” 894 F.3d 721, 737 (6th Cir. 2018) (quoting Miller v. Calhoun County, 408 F.3d 803, 819 (6th Cir. 2005)). Applying Rhinehart’s standard, the court held that because Horton failed to show grossly incompetent or inadequate care, he failed to satisfy the objective component. Rhinehart quotes Miller when incorporating the grossly inadequate standard into the objective component. Id. But Miller held that, in cases involving allegedly inadequate medical treatment, evidence that treatment was “so grossly incompetent, inadequate, or excessive” provides one way of establishing deliberate indifference that is separate from the objective and subjective standards of Farmer. 408 F.3d at 819. In other words, it is not the case that a plaintiff must show both gross inadequacy and evidence of serious medical needs to satisfy the objective component; one or the other is sufficient. Miller therefore did not incorporate the grossly inadequate standard into the objective component, see id., and our post-Miller cases confirm this. See Santiago v. Ringle, 734 F.3d 585, 590 (6th Cir. 2013). “It is therefore unclear why [Rhinehart] included this language as part of the objective component.” Est. of Majors v. Gerlach, 821 F. App’x 533, 540 n.6 (6th Cir. 2020).

The district court applied an incorrect test, and, as a result, erred in holding that Horton failed to satisfy the objective component.

2. Subjective Component

The questions under the subjective component are whether Dr. Guerrant and N.P. Hendrix Labonte (1) perceived a substantial risk of harm to Horton, (2) inferred this risk, and (3) disregarded it. Comstock v. McCrary, 273 F.3d 693, 703 (6th Cir. 2001) (citing Farmer, 511 U.S. at 837). To satisfy this prong, Horton does not need to show that Defendants acted “for the very purpose of causing harm or with knowledge that harm will result,” but he must show that they acted with “more than mere negligence.” Santiago, 734 F.3d at 591 (quoting Farmer, 511 U.S. at 835). And a prison official may “not escape liability if the evidence showed that he merely refused to verify underlying facts that he strongly suspected to be true, or declined to confirm inferences of risk that he strongly suspected to exist.” Farmer, 511 U.S. at 843 n.8. As the Supreme Court explained, “[w]hether a prison official had the requisite knowledge of a substantial risk is a question of fact subject to demonstration in the usual ways, including inference from circumstantial evidence, and a factfinder may conclude that a prison official knew of a substantial risk from the very fact that the risk was obvious.” Id. at 842 (citation modified); see also Santiago, 734 F.3d at 591. Such language reminds us that fact and evidence-based questions are less well suited to summary judgment.

Horton argues that Dr. Guerrant and N.P. Hendrix Labonte were deliberately indifferent to his thoracic back condition and resulting paralysis by continuing to pursue a proven ineffective course of treatment with pain medication despite their knowledge of his worsening condition. Because § 1983 claims cannot rest on vicarious liability, we evaluate this prong as to Dr. Guerrant and N.P. Hendrix Labonte separately. See Shadrick, 805 F.3d at 737.

a. Dr. Guerrant

Dr. Guerrant, Horton’s doctor at NWCX, began treating Horton’s spinal issues in February 2021, and continued this treatment until Horton’s hospitalization and paralysis in December 2022.

For the first question of the subjective component, we begin with the facts Dr. Guerrant perceived from which he could infer a risk of serious harm to Horton. See Comstock, 273 F.3d at 703. Following Horton’s February 2021 diagnosis of degenerative disease of the cervical and lumbar spine, Dr. Guerrant became aware as early as June 2022 of inconsistencies between Horton’s previous MRI findings and his presenting symptoms. In October, Dr. Guerrant’s medical notes confirm that Horton was experiencing new symptoms that involved pain in the “midback [in the] mid thoracic to mid lumbar area,” and that this pain and numbness was occurring with no new injury. R. 97-1, PageID 2277. Such information was concerning enough for Dr. Guerrant to order a thoracic MRI to rule out “more cephalad injury.” R. 97-1, PageID 2277.

When the October MRI was denied, Dr. Guerrant reviewed the denial’s explanation of what additional documentation would be necessary to secure a thoracic MRI: documentation of an NSAID trial for at least three weeks, a home exercise regime for at least six weeks, activity modifications for at least six weeks, and new deficits in Horton’s progress notes. At the time of the MRI denial, Dr. Guerrant’s own treatment of Horton establishes that these benchmarks had already been met: Dr. Guerrant began prescribing Horton NSAIDs more than a year earlier, ordered Horton special accommodations four months before, and knew that Horton had been actively engaging in physical therapy for four months. Dr. Guerrant, however, did not resubmit the MRI request until a month and a half later, on November 30. During that delay, Horton continued to complain of “severe back pain.” R. 97-1, PageID 2257. On December 8, Dr. Guerrant was read the following X-ray results: “T8 and T9 vertebral body height loss . . . [c]omplete disc height loss at T8–T9,” and “[c]omplete loss of disc height at T8–T9 concerning for compression fractures, discitis/osteomyelitis, and/or malignancy, new since prior.” R. 97-1, PageID 2256. And at Dr. Guerrant’s deposition, he testified to his knowledge that “osteomyelitis” is an “infection of the bone.” R. 94-3, PageID 2047.

In considering Dr. Guerrant’s perception, the district court improperly drew two factual inferences in Dr. Guerrant’s favor at summary judgment. First, it assumed that when Dr. Guerrant was read the December 2 X-ray results on December 8, he was aware that his second thoracic MRI request in November had already been granted. But when Dr. Guerrant was asked at his deposition about what he would have told Horton at the December 9 appointment, he responded the following

A. That he had an abnormal X-ray. . . . And that we’re waiting for the results of the MRI.

Q. . . . And the MRI was scheduled for when?

A. I don’t know, at the time. It was ordered the same time as the back X-ray.

Q. Yes, sir. Did you attempt at any time to have an MRI done earlier than it was scheduled after you saw the X-ray of 12/02 of 2022?

A. No.

Q. Why not?

A. It had been ordered, and I didn’t–you know, his condition hadn’t changed. So it didn’t feel that it was urgent. R. 94-3, Dr. Guerrant Dep., PageID 2051–52. Viewing this testimony in the light most favorable to Horton supports an inference that Dr. Guerrant did not know whether Horton’s thoracic MRI had been approved or scheduled on December 8, when Dr. Guerrant received the X-ray results, or on December 9, when he prescribed Horton pain medication. See Chapman, 670 F.3d at 680. Second, the district court held that a dispute exists over the extent to which Dr. Guerrant perceived Horton’s immobility when he prescribed the pain medication on December 9. But Dr. Guerrant testified during his deposition that when the nurse called on December 8 and read him the X-ray results, he “was told that [Horton] was brought to the clinic in a wheelchair.” R. 94-3, PageID 2086. Viewing this evidence in the light most favorable to Horton results in the inference that Dr. Guerrant was aware of the extent of Horton’s immobility when he treated Horton on December 9. See Chapman, 670 F.3d at 680.⁵5. The partial dissent asks us “to go a step further and show that Dr. Guerrant knew that ordering the MRI and waiting for the results was not good enough.” Partial Dissent at 24. This opinion has already done this. As stated above, viewing the evidence in the light most favorable to Horton allows inferences that Dr. Guerrant was aware that Horton’s thoracic condition was worsening and now included his immobility, while waiting on the MRI results. See record citations in Part III.A.2.a.

This leads us to the second inquiry of the subjective prong, whether Dr. Guerrant drew the inference that there was a substantial risk to Horton. See Comstock, 273 F.3d at 703. Viewing the facts in the light most favorable to Horton, a reasonable jury could conclude that Dr. Guerrant recognized the risk associated with Horton’s worsening thoracic condition. By December 2022, Dr. Guerrant could reasonably be found to have inferred that Horton had developed symptoms in the thoracic area of his spine that were distinct from his preexisting back conditions, that Horton’s condition had deteriorated to the point that he required a wheelchair, that the risk was serious enough to warrant Dr. Guerrant ordering another MRI and X-ray, and that the X-ray findings raised concerns for a spinal infection, fractures, and/or malignancy. Taken together, this evidence creates a genuine dispute as to whether Dr. Guerrant inferred that Horton faced a substantial risk of serious harm from a new, worsening spinal condition. See Dominguez, 555 F.3d at 550–51.

The third inquiry is whether Dr. Guerrant disregarded the risk. See Comstock, 273 F.3d at 703. Here, the record is plain. After receiving the above information and not knowing whether a thoracic MRI had even been scheduled, R. 94-3, PageID 2051–52, Dr. Guerrant did not attempt to expedite the MRI, did not send Horton to the emergency room, nor did he otherwise escalate treatment in any way. Instead, he continued to prescribe the pain medication that he had been prescribing for over a year.

The district court held that Horton had not shown a genuine issue of material fact about Dr. Guerrant’s deliberate indifference on the basis that Horton’s arguments merely amount to a disagreement over the appropriate course of treatment, or that Dr. Guerrant misdiagnosed Horton by treating the new thoracic condition in the same way as Horton’s preexisting conditions. This misconstrues Horton’s argument. He does not contend that Dr. Guerrant should have selected one reasonable treatment option over another. Rather, Horton presented evidence that, as his condition progressively deteriorated and objective findings increasingly indicated a new serious spinal condition, Dr. Guerrant persisted in the same ineffective treatment despite evidence that it had not improved Horton’s condition.

To support his argument, Horton relies on Darrah v. Krisher, 865 F.3d 361 (6th Cir. 2017). There, the plaintiff’s skin condition responded to only one medication, and several alternative medications had proven ineffective. Id. at 364. When the plaintiff was transferred to a new correctional institution, he was not given the proper medication; instead, he was given an alternative that failed to treat his condition. Id. at 364–66. Although the providers knew the plaintiff’s condition could lead to infection, they nevertheless continued the ineffective treatment for months over the plaintiff’s repeated complaints that the alternative treatment was not working and his condition was worsening. Id. at 364–66. On those facts, we held that “the question of whether it was reasonable to continue to keep [the plaintiff] on a drug that had proven ineffective and whether that course of treatment constituted deliberate indifference is a question best suited for a jury.” Id. at 370. The same is true here: Horton repeatedly complained that his condition was worsening and that the prescribed pain medication was not alleviating his symptoms; and as in Darrah, Dr. Guerrant knew Horton’s condition continued to deteriorate despite more than a year of treatment with pain medication that had proven ineffective. See id at 364–66.⁶6. The record citations in Part III.A.2.a. rebut the dissent’s argument that there is no evidence of Dr. Guerrant’s subjective knowledge.

Defendants argue that this case is distinct from Darrah because, unlike the providers there, Dr. Guerrant did not know the specific condition Horton suffered from (a spinal infection). Id. at 364. But deliberate indifference does not require knowledge of the plaintiff’s precise diagnosis or the exact harm that ultimately occurred. See Dominguez, 555 F.3d at 550. Rather, Horton need only show that Dr. Guerrant “knew that serious risks accompany” Horton’s worsening thoracic condition, which continued to deteriorate despite conservative treatments and progressed to the point that Horton could no longer walk. See id. And viewing the evidence in the light most favorable to Horton, a reasonable jury could conclude that he made that showing. Horton has therefore presented sufficient evidence to create a genuine dispute of material fact as to whether Dr. Guerrant acted with deliberate indifference, thereby precluding summary judgment. See Fed. R. Civ. P. 56(a). We accordingly reverse the district court’s holding on the claim against Dr. Guerrant.

b. N.P. Hendrix Labonte

Horton’s deliberate indifference claim against N.P. Hendrix Labonte is not as strong. Although N.P. Hendrix Labonte treated Horton from March 2021 until his hospitalization in December 2022, her care consisted of evaluations, documenting his symptoms, ordering EKGs and lab tests, prescribing him steroids and Icy Hot, and referring him to a physician, physical therapist, or pain management specialist. Horton does not contend that any of these actions independently constitute deliberate indifference. Instead, his arguments rest entirely on the actions of Dr. Guerrant, and although Labonte worked with Dr. Guerrant in devising plans regarding Horton’s imaging, the record reflects that Dr. Guerrant ultimately ordered and interpreted Horton’s X-rays and MRIs. As we noted above, Section 1983 claims cannot rest on vicarious liability, and thus Horton has failed to establish a genuine dispute of material fact as to N.P. Hendrix Labonte’s deliberate indifference. See Shadrick, 805 F.3d at 737. We affirm the district court’s grant of summary judgment in N.P. Hendrix Labonte’s favor on the claim against her.

B. Monell Claim Against Centurion

Horton also brought a claim of municipal liability against Centurion pursuant to Monell v. Department of Social Services of City of New York, 436 U.S. 658 (1978). Centurion is a private company that provides healthcare to inmates in state prison systems and is contracted to provide healthcare at TDOC facilities. A private entity, such as Centurion, can be held liable under § 1983 when it is carrying out a traditional state function such as providing healthcare services. See Johnson v. Karnes, 398 F.3d 868, 877 (6th Cir. 2005). To hold Centurion liable under Monell, Horton may rely on one of the four recognized theories: “(1) the existence of an illegal official policy or legislative enactment; (2) that an official with final decision making authority ratified illegal actions; (3) the existence of a policy of inadequate training or supervision; or (4) the existence of a custom of tolerance or acquiescence of federal rights violations.” Burgess v. Fischer, 735 F.3d 462, 478 (6th Cir. 2013).

On appeal, Horton argues that Centurion had a policy of inadequate supervision of medical staff that resulted in a violation of his constitutional rights. Specifically, he contends that inadequate supervision caused Dr. Guerrant and N.P. Hendrix Labonte not to receive on December 11 his SCRs, which stated that he was losing the use of his legs and he needed to go to the hospital, and that their failure to receive these SCRs played a role in his paralysis. The district court granted summary judgment in Centurion’s favor, holding that Horton failed to prove the existence of a policy or custom of inadequate supervision because he alleged only the single episode of his faulty care.

Horton can establish Centurion’s failure to adequately supervise in two ways: showing either (1) a “pattern of similar constitutional violations by untrained employees” coupled with Centurion’s “continued adherence to an approach that it knows or should know has failed to prevent tortious conduct” or (2) “a single violation of federal rights, accompanied by a showing that [the municipality] has failed to train its employees to handle recurring situations presenting an obvious potential for a constitutional violation.” Shadrick, 805 F.3d at 738–39 (citation modified). Because Horton identifies only his single constitutional violation, he also needs to show that Centurion failed to train its employees in responding to prisoners’ medical requests. See id. Defendants argue that although Horton alleged more than a dozen inadequate customs and policies below, this theory was not one of them, so he cannot now raise it for the first time on appeal. But we need not decide this preservation issue, because, regardless, Horton’s one paragraph argument fails as he does not cite any record evidence on Centurion’s training regarding SCRs. We will not address “issues adverted to in a perfunctory manner, unaccompanied by some effort at developed argumentation,” nor will we reconstruct a party’s argument for them. United States v. Elder, 90 F.3d 1110, 1118 (6th Cir. 1996) (citation modified). We therefore affirm the district court’s grant of summary judgment in Centurion’s favor on this claim.

C. State Medical Negligence Claims

Horton raised claims of medical negligence in violation of the Tennessee Health Care Liability Act. The district court declined to exercise supplemental jurisdiction over these state law claims because it dismissed all of Horton’s federal claims. Because we reverse the district court’s grant of summary judgment as to the federal § 1983 claim against Dr. Guerrant, we vacate the district court’s dismissal of the state law claims and remand these claims for the court’s consideration of its supplemental jurisdiction in light of this opinion.

IV. CONCLUSION

For the foregoing reasons, we REVERSE the district court’s grant of summary judgment in favor of Dr. Guerrant as to Horton’s § 1983 deliberate indifference claim; AFFIRM the grant of summary judgment in favor of N.P. Hendrix Labonte on the deliberate indifference claim and in favor of Centurion on the Monell claim; and VACATE the dismissal of Horton’s state law claims, REMANDING them for consideration in light of this opinion. JOHN K. BUSH, Circuit Judge, concurring in part and dissenting in part. I agree with the majority that Horton does not provide any basis for imposing Monell liability on Centurion, and there is no evidence that N.P. Labonte knew that Horton needed more care than she was giving him. I disagree, however, with the majority’s conclusion that Dr. Guerrant was deliberately indifferent. To establish deliberate indifference, Horton must show that Dr. Guerrant was “aware of facts from which the inference could be drawn that a substantial risk of harm exists” and that Dr. Guerrant actually “dr[e]w that inference.” Farmer v. Brennan, 511 U.S. 825, 837 (1994). In other words, Horton needs to prove that Dr. Guerrant “was subjectively aware” that Horton was not receiving adequate care. Id. at 829. Importantly, Dr. Guerrant had already ordered an MRI for Horton, so Horton can prevail only if he provides some evidence in which the court can infer that Dr. Guerrant subjectively knew that he needed emergency care. Horton has not given any evidence to draw such a conclusion. In fact, the record indicates the contrary. When asked about his response to the X-ray results at his deposition, Dr. Guerrant said that Horton’s “condition hadn’t changed” and that he “didn’t feel that it was urgent.” R. 90-5, Guerrant Dep., PageID 1223. Additionally, the X-ray results do not say that they were emergent or otherwise warranted immediate action. So not only does Dr. Guerrant deny subjectively believing that Horton needed something beyond an MRI, but there is nothing in the record from which we could impute that knowledge. Horton had the burden to put on “affirmative evidence” in support of his argument that Dr. Guerrant subjectively knew that ordering the MRI was not good enough under the circumstances. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 257 (1986). There is no such evidence. Horton’s arguments on appeal are unavailing. He claims that Dr. Guerrant subjectively knew of the risk to Horton because Horton reported being in pain. But Dr. Guerrant gave Horton pain medication. I do not think a reasonable jury would believe that Dr. Guerrant subjectively knew giving pain medication was insufficient treatment given Horton’s medical history. Horton also argues that Dr. Guerrant should have ordered a blood test to determine if he had an infection, but he presents no evidence that Dr. Guerrant knew he needed to order that blood test. Without evidence of that subjective knowledge, Horton’s complaints boil down to disagreement over a treatment plan, which is not enough for deliberate indifference. See, e.g., Westlake v. Lucas, 537 F.2d 857, 860 n.5 (6th Cir. 1976). The majority takes a slightly different position from Horton. My colleagues conclude that Dr. Guerrant should have insisted on the MRI in October because Horton started experiencing the new symptoms in June and that Horton had already completed the proposed alternative treatment plan by October. See Majority Op. at 13–14. But this conclusion is bereft of factual support. As to the June 2022 appointment, the undisputed record evidence shows that on June 13th, “Horton was seen by Dr. Guerrant, . . . who documented Horton’s medical history including physical therapy and ESIs and noted inconsistencies between the MRI findings and Horton’s symptoms, the sporadic nature of his symptoms, and his normal functioning between episodes.” R. 97-16, Pltf’s Resp. to Defs’ SMF, PageID 2551. Horton did not dispute these facts, nor do they suggest that Horton was experiencing new symptoms by June 2022. Rather, the undisputed record evidence shows that the symptoms for which the October 2022 MRI was requested first manifested on “October 3” of that year, when he “submitted another SCR . . . complaining his back gave out and that pain medication and Icy Hot were not reducing the pain.” Id. at PageID 2555. The majority’s contrary read of the record is simply mistaken. The majority also concludes that the evidence, when viewed in Horton’s favor, “supports an inference that Dr. Guerrant did not know whether” the November 2023 MRI request had been granted. Majority Op. at 14. But there is no explanation as to why this matters. Once Dr. Guerrant ordered the MRI, he facially complied with his constitutional obligations. See Phillips v. Tangilag, 14 F.4th 524, 538 (6th Cir. 2021). Horton’s claim, therefore, cannot be that Dr. Guerrant was deliberately indifferent solely on the basis that Dr. Guerrant failed to order an MRI. The majority thus needs to go a step further and show that Dr. Guerrant knew that ordering the MRI and waiting for the results was not good enough. But the majority fails to make that showing. Indeed, if anything, the record evidence demonstrates that Dr. Guerrant subjectively believed that waiting for the already ordered, non-emergent MRI result was sufficient. The majority believes that that the record “allows inferences that Dr. Guerrant was aware that Horton’s thoracic condition was worsening . . . while waiting on the MRI result.” Majority Op. at 17 n.6. But the majority’s own record citation provides concrete, not inferential, evidence that Dr. Guerrant had no subjective knowledge about any risk for awaiting the already ordered MRI testing. Again, when asked why he did not attempt to have Horton’s MRI moved up to an earlier date after reviewing the December 2nd X-ray, Dr. Guerrant responded, “It had been ordered, and I didn’t– you know, his condition hadn’t changed. So it didn’t feel that it was urgent.” R. 90-5, Guerrant Dep., PageID 1223. This statement is the only dispositive evidence as to whether Dr. Guerrant had subjective knowledge that failure to move up the already scheduled MRI would pose a substantial risk to Horton. Horton’s illness and subsequent injury are profoundly tragic. But the case law states repeatedly that we cannot use the Eighth Amendment to “constitutionaliz[e] medical malpractice claims.” Comstock v. McCrary, 273 F.3d 693, 703 (6th Cir. 2001). Perhaps Dr. Guerrant should have known better when Horton fell ill. But that does not mean that he did know better, nor does it mean that Dr. Guerrant “consciously disregarded” Horton’s health risk. Because there is no evidence to support such findings, I respectfully dissent.