Full opinion text
CASE MANAGEMENT ORDER NO. 100 This Order relates to the cases listed in Appendix 1 Richard Mark Gergel, United States District Court Judge Before the Court is Defendant’s Omnibus Motion for Summary Judgment, (Dkt. No. 1564). For the reasons stated below, the motion is GRANTED IN PART. I. Background A. Procedural History On February 18, 2014, the Judicial Panel on Multidistrict Ligation created this MDL, centralizing cases where female plaintiffs “allege that they have developed type 2 diabetes as a result of taking Pfizer’s cholesterol-lowering drug Lipitor.” (Dkt. No. 1 at 1). Plaintiffs allege that Defendant failed to warn physicians and consumers adequately of the risk of developing Type 2 diabetes from taking Lipitor, knew or should have known that taking Lipitor increased the risk of developing Type 2 diabetes, and negligently, recklessly, and carelessly marketed Lipitor without adequate instructions or warnings. (See id., Dkt. No. 160). This Court held an initial status conference on March 27, 2014, and, after a second status conference on April 25, 2014, discovery commenced when the Court entered CMO 4, which among other things, set forth an initial discovery plan. (Dkt. No. 101 at 17-24). This plan provided for certain document production by Pfizer (including electronic discovery), interrogatories served by Plaintiffs on Pfizer, and depositions of Pfizer and its current and former employees. (Id.) On May 2, 2014, the Court entered CMO 5, which required Plaintiffs to serve Plaintiff Fact Sheets and certain mandatory disclosures on Pfizer. (Dkt. No. 110). With discovery underway, the Court turned to the process for selecting a bellwether case for trial. Under Amended CMO 6, entered on May 22, 2014, the Plaintiffs’ Steering Committee (PSC) and Defendant each selected seven (7) cases for the Discovery Pool in June of 2014. (Dkt. No. 148 at 4). More in depth case specific discovery was taken in these 14 cases in the Fall of 2014, including the propounding of written discovery on Discovery Pool Plaintiffs, depositions of Discovery Pool Plaintiffs, immediate family members and healthcare providers, depositions Pfizer sales representatives, and completion of a Defendant Fact Sheet by Pfizer. (Id. at 5). On January 30, 2015, the Court convened the parties to randomly select the first cases for bellwether trials from the Discovery Pool cases. (Dkt. No. 739). By stipulation, the parties narrowed the fourteen (14) Discovery Pool cases to four (4) eases. The Court then randomly selected the first bellwether trials from these four (4) cases. The first case selected was Daniels v. Pfizer, Case No. 2:14-cv-01400, and the second case selected was Hempstead v. Pfizer, Case No. 2:14-cv-01879. Thereafter, the parties conducted additional case-specific discovery in these two cases. (See CMO 29, Dkt. No. 746; CMO 30, Dkt. No. 790). From the beginning of this MDL, the parties have agreed that Plaintiffs must prove both general and specific causation as elements of their claims and have litigated this case as if expert testimony is needed to prove both. General causation is whether a substance is capable of causing a particular injury or condition (in this instance, whether Lipitor is capable of causing diabetes); specific causation is whether the substance caused the injury of the particular plaintiff at issue (in this instance, whether Lipitor caused Ms. Hempstead’s diabetes). E.g., Norris v. Baxter Healthcare Corp., 397 F.3d 878, 881 (10th Cir. 2005). “Plaintiff[s] must first demonstrate general causation because without general causation, there can be no specific causation.” Id. Here, if Lipitor is not capable of causing diabetes, it follows that it is not the cause of diabetes in particular plaintiffs. The parties served common expert disclosures, including general causation experts, in March and April of 2015. (See CMO 29, Dkt. No. 746). Over Defendant’s objection, the Court allowed Plaintiffs to supplement these disclosures in May of 2015 “to ensure this Court has the best information possible when addressing Daubert motions.” (CMO 34, Dkt. No. 869 at 2). The parties then served specific causation expert disclosures in the two bellwether cases, in May and June of 2015. {See CMO 29, Dkt. No. 746; CMO 34, Dkt. No. 869). The Court allowed Plaintiffs to serve a rebuttal report by one of these case specific experts, again over Defendant’s objection. (See CMO 38, Dkt. No. 967). After full discovery, Defendant filed motions to exclude Plaintiffs’ general causation expert testimony as well as Plaintiffs’ specific causation expert testimony in the two bellwether eases. (Dkt. Nos. 972,1004, 1006). As more fully explained below, after extensive briefing and oral argument, the Court ultimately excluded Plaintiffs’ expert testimony on general causation with respect to dosages of less than 80 mg. (See CMO 49, Dkt. No. 1197; CMO 68, Dkt. No. 1469). The Plaintiffs at issue here all ingested dosages of Lipitor less than 80 mg. Thus, the Plaintiffs here do not have admissible expert testimony on general causation. As explained in more detail below, the Court also excluded the expert testimony of Dr. David Handshoe and Dr. Elizabeth Murphy, the two specific causation experts in the bellwether cases because their opinions were based on nothing more than an increased risk and temporal association. (CMO 55; Dkt. No. 1283; CMO 76, Dkt. No. 1517). However, Plaintiffs noted that in the SPARCL study, patients with certain characteristics and taking 80 mg of Lipitor had a relative risk ratio of developing diabetes greater than 2.0, meaning it was more likely than not that these individuals would not have developed diabetes in the absence of Lipitor. Thus, it was possible that Plaintiffs with such characteristics and taking 80 mg of Lipitor might be able to proffer a specific causation expert opinion that would survive Daubert, even if the Court’s ruling in CMO 55 was correct,' and the Court entered a scheduling order to identify and take to trial such a case. (See CMO 61, Dkt. No. 1323). However, in a hearing on the matter on January 22, 2016, Plaintiffs’ Lead Counsel stated that there was no plaintiff in the MDL that met those criteria. (Dkt. No. 1347 at 5). Thus,' the Court turned to where that left the MDL proceedings: THE COURT: Let’s talk for just a minute about where that leaves us .... let me ask this first from the plaintiffs: Is there any reason to believe that if we picked a 20- or 40- milligram case to try as a bellwether that you would have any class of cases or factual presentation or new theory that might survive specific causation, assuming the correctness of the Murphy order? Mr. Hahn? MR. HAHN: The short answer is no, sir, Your Honor, we don’t. Given the Murphy order and the Court’s reading of the medicine, we are not going to be able to get a differential diagnosis that’s going to survive. THE COURT: ' Well, it’s not a differential diagnosis, you’ve got to show specific causation more likely than not. And you have an opinion to that But if we assume for a minute- that the critical question then is whether the Court is correct regarding the standard, if you are telling me, Mr. Hahn, that if I’m correct, then you’re not going to have a case that survives summary judgment? MR. HAHN: Yes, Sir.', (Dkt. No. 1347 at 9-10). The Court went on to discuss with counsel options for proceeding within the MDL. Defendant’s Lead Counsel suggested the Court issue an order to show cause to see if any Plaintiff could differentiate her case and then, if not, grant summary judgment in all cases, and Plaintiffs’ Lead Counsel agreed: MR. CHEFFO [Defendant’s Lead Counsel]: ... So I think what is most efficient for this litigation ... is to have that ultimately reviewed, right? And I think that what other courts' in similar situations have done is they have basically said, just issue an order to show cause and said, look, you know, if anybody thinks that they are differently situated or has some kind of different argument or something else, they can come forward; if not, what we are going to do is we are going to grant judgment on that. .... they would then ,,, presumably get appealed to the Fourth Circuit and the Circuit Court would do what it’s going to do. And I think that’s the appropriate ... remedy in an MDL. .-... the most efficient way is to expeditiously grant summary judgment for all the cases on that ground, and anything else, get to the Fourth Circuit and have the Court review it. THE COURT: Mr. Hahn, what your thoughts?' MR. HAHN [Plaintiffs’ Lead Counsel]: Judge, I—I believe that Mark was cheating and reading off of my notepad. We basically agree. (Dkt. No. 1347 at 11-13). The Court took counsel’s suggestion and issued CMO 65, which stated, NOTICE: THIS ORDER CONTAINS AN IMPORTANT DEADLINE FOR ALL PLAINTIFFS. Lead Plaintiffs’ counsel advised the Court in an on the record telephone conference of January 22, 2016, that, if the Court’s ruling excluding the expert testimony of Dr. Elizabeth Murphy (CMO 55, Dkt, No. 1283) is correctly decided, then none of the cases now pending in the MDL will be able to survive summary judgment on the issue of specific causation. Notice is hereby given that any Plaintiff who disputes the position taken by Plaintiffs’ Lead Counsel and asserts that her case can survive summary judgment on specific causation even if the Court’s ruling in CMO 55 is upheld on appeal, such Plaintiff shall provide notice to the Court within 15 days of this' order and set forth with specificity how her case is distinguished from the Court’s ruling in CMO 55. The Court will then promptly set a schedule in each such case for identifying expert witnesses, submitting expert reports, deposing identified experts, and briefing Daubert and dispositive motions. (Dkt. No. 1352). CMO 65 did not require any Plaintiff to marshal any evidence within 15 days. The Order only required that Plaintiffs give notice -within the 15-day period. The Court explicitly stated that if any Plaintiff came forward, it would then set a pre-trial schedule in those case(s), allowing Plaintiffs time to develop expert testimony. However, not a single Plaintiff came forward. Nor did a single Plaintiff ask for an extension of time to file a notice in response to CMO 65. This Order was issued on January 25, 2016, and now, nearly eleven months later, still not a single Plaintiff has come forward in response to this Order and asked to proceed with her case. On June 9, 2016, the Court held a Status Conference to discuss proceeding with summary judgment. (Dkt. No. 1550). Plaintiffs, for the first time, had appellate counsel appear in front of the Court. (Id.). It was in this conference that Plaintiffs’ counsel indicated, for the first .time in this litigation, that some plaintiffs may possibly be able to survive summary judgment despite the Court’s Daubert rulings: MR. HAHN: ... And by taking up 10, 20, and 40, your general causation opinions, and then Murphy’s specific causation opinion, I don’t think we can have a summary judgment as to all the other plaintiffs in the litigation, because those other plaintiffs, in some states you don’t have to have [an] expert—New Mexico is one—.... there may be other plaintiffs that have—haven’t had the opportunity, and plan to put up a specific causation expert that’s going to give an opinion that would get them to a jury. THE COURT: No, no, I had—I entered an order, Mr. Hahn, in which I said if any of you don’t agree with the lead counsel’s position about specific causation, you need, by a designated date, to identify your case and provide me the names of your experts, so we can get on with discovery. MR. HAHN: Yes, sir. THE COURT: So I don’t think we’re out there with other potential cases. Now this issue of states that do not require expert testimony on causation, ... I wasn’t aware there were such states. (Dkt. No. 1550 at 7). The Court went on to state: “let’s assume there are. Then the brief in opposition could say all claims from the following—from the State of New Mexico, we oppose it, because there’s not a[n expert] requirement .... the plaintiff would still have to make a showing of whatever is required under that law to establish causation, even if you don’t need an expert...” (Id. at 9). Thus, Court set a scheduling for briefing,on summary judgment, (CMO 79, Dkt. No. 1548), and Plaintiffs had an opportunity to come forward with evidence under this new theory in opposition to summary judgment. However, when the deadline for opposition to summary-judgment came á month- and-a-half later, not a single Plaintiff came forward with evidence that she claimed precluded the entry of summary judgment. Instead, Plaintiffs argued that it was theoretically possible that some unidentified Plaintiff(s) may possibly have some unidentified circumstantial, non-expert evidence of specific causation. (Dkt. No. 1586). In this opposition, Plaintiffs readily acknowledged that any Plaintiff “who believed she could adduce a differential diagnosis that could survive Daubert notwithstanding the exclusion of Dr. Murphy’s expert testimony in Hempstead” should have come forward in response to CMO 65, (Dkt. No. 1586 at 13), but argued that Plaintiffs should be allowed to present non-expert testimony to transferor courts after remand. Given this speculative response, the Court gave Plaintiffs a third opportunity to come forward if any thought her case could survive summary judgment. The Court issued CMO 81, which stated in part: NOTICE IS HEREBY GIVEN that any Plaintiff who asserts that her case can survive summary judgment on specific causation even if the Court’s ruling in CMO 55 is upheld on appeal, must file a response to Defendant’s motion for summary judgment (Dkt. No. 1564) within fifteen (15) days of the date of this Order. Any such response must specifically identify the particular Plaintiff opposing summary judgment, identify the substantive state law that she contends applies to her claims, and include all evidence that she asserts precludes the entry of summary judgment in her case. If any Plaintiff contends that she needs additional case-specific discovery to provide such evidence, she must comply with the requirements of Fed. R. Civ. P. 56(d) and identify the specific facts that are yet to be discovered. Should the claims of any Plaintiff survive summary judgment based on Rule 56(d), the Court will then promptly enter a scheduling order in each such case allowing for appropriate discovery and the filing of dispositive motions after discovery. (Dkt. No. 1599 at 3-4). Again, not a single Plaintiff came forward with evidence of specific causation. Nor did a single Plaintiff make an individualized Rule 56(d) request. Instead, Plaintiffs filed an omnibus response arguing that, other than the two bellwether Plaintiffs, no Plaintiff has had an opportunity to develop the facts of her case. (Dkt. No. 1611). Inexplicably, Plaintiffs argued that none of the Plaintiffs (other than the two bellwether Plaintiffs) have had an opportunity to “hire experts” or “prepare expert reports,” (Dkt. No. 1661 at 8), despite the fact that CMO 65 offered any Plaintiff the opportunity to do just that. In the Rule 56(d) affidavit filed with Plaintiffs’ response, Plaintiffs stated that they needed an opportunity to seek (1) “[ejvidence, testimony, and (if necessary) third-party discovery from their treating physicians,” (2) “[ejxpert opinions regarding specific causation,” and (3) “their patient records.” (Dkt. No. 1611-1). Plaintiffs did not state any other information that they need to seek to defend against this motion for summary judgment. Thus, the Court issued CMO 82. First, the Court held that the time for Plaintiffs to come forward and argue that they could produce expert testimony on specific causation had passed: As an initial matter, the time for a Plaintiff to come forward and argue that she could produce an expert opinion on specific causation that would survive Daubert has passed. The Court issued an order to show cause on this seven months ago, and explicitly stated that it would allow any such plaintiff to proceed with discovery and pre-trial proceedings, and in the last seven months not a single Plaintiff has come forward. Plaintiffs’ Lead Counsel testifies that he understood his admission at the January 22, 2016 status conference as a confirmation “on the ability of Plaintiffs to survive the evidentiary standards for specific-causation expert evidence set forth in CMO 55” and that he understood CMO 65 to “relate to whether individual Plaintiffs believe their case could survive the Rule 702 expert standards in CMO 55.” (Dkt. No. 1611-1 at 6-7). Whatever the dispute about non-expert evidence, there can be no dispute, and according the Plaintiffs’ Lead Counsel’s affidavit, there is no dispute, that any Plaintiff who believed she could proffer expert evidence on specific causation that would survive Rule 702 and Daubert was required to come forward in response to CMO 65. (See also Dkt. No. 1611 at 17 (“CMO 65 directed any Plaintiff who thought they could survive summary judgment on specific causation in light of the Court’s exclusion of Dr. Murphy in CMO 55 (Doc. 1283) to come forward with new or additional expert evidence.”); Dkt. No. 1611 at 18 (“Plaintiffs continued to understand the Gourt’s order to relate to whether individual Plaintiffs believed their case could survive the Rule 702 expert standards in CMO 55, not the separate legal issue of whether the law of their state requires expert evidence.”)). No Plaintiff has done so. Therefore, Plaintiffs’ argument that they have not had an opportunity to seek specific causation expert testimony is meritless. The Court provided that opportunity in CMO 65, not a single Plaintiff came forward, and by not coming forward in response to CMO 65, Plaintiffs have waived that argument. (Dkt. No. 1616 at 7-8 (emphasis in original)). The Court went on to provide Plaintiffs with a fourth and final opportunity to come forward with non-expert evidence: With regard to non-expert evidence, in an abundance of caution, the Court will provide Plaintiffs with a fourth and final opportunity to come forward. Plaintiffs have argued that 15 days is not sufficient time to marshal their evidence. Thus, the Court will afford them an additional 60 days. The Court notes that the only facts that Plaintiffs have stated they may need to discover (other than expert testimony) to defend against summary judgment is information from their own treating physicians and their own patient records. (Dkt. No. 1611-1 at 5). They have not requested any discovery from Defendants or other third-parties. Given the nature of the evidence that Plaintiffs claim they need time to marshal, specifically their request to marshal their own medical records and information from their own treating physicians, the Court finds 60 days sufficient. (Id. at 8). In response to CMO 82, no Plaintiff made a Rule 56(d) motion. Thus, the additional 60 days did prove sufficient. In addition to the omnibus responses to summary judgment filed by the Plaintiffs’ Steering Committee, (Dkt. Nos. 1586, 1611, 1684), two sets of Plaintiffs filed responses to CMO 82. Thirty-four Plaintiffs (“the Hayes Law Firm Plaintiffs”) submitted their Plaintiff Fact Sheets (PFSs) and certain medical records. (Dkt. Nos. 1670, 1682, 1686, 1687, 1688). They contend that (1) they were not diabetic before taking Lipitor, (2) they were diagnosed with diabetes after taking Lipitor, and (3) they did not have certain risk factors for diabetes, even though they had others. (See Dkt. No. 1670 at 17-39). At oral argument counsel stated this was “the best thing 1 could come up with with nonexpert evidence,” that “[tjhey are not diabetic before taking the medication, they took Lipitor and then they became diabetic.” (Dkt. No. 1727 at 24). The Douglas & London Plaintiffs did not initially submit any evidence to the Court and simply argued that summary judgment was precluded by: (a) their respective health history and conditions as documented in their medical records, pharmacy records and/or other relevant records; (b) their respective Plaintiff Fact Sheets (“PFS’s”) that have already been served on Defendants and any and all amendments thereto; (c) the general causation evidence identified and discussed in Plaintiffs’ Opposition to Defendants’ Omnibus Motion for Summary Judgment dated July 22, 2016 [Dkt. 1686]; and (d) the substantive state law that applies to each D&L Plaintiffs respective claims. (Dkt. No. 1689 at 5 (footnotes omitted)). The Court entered a text order stating that these Plaintiffs must submit to the Court any evidence that they wished to the Court to consider. (Dkt. No, 1695). In response, Plaintiffs literally dumped boxes upon boxes of documents on the Court, with no discernment or suggestion as to which documents they claimed precluded summary judgment. (Dkt. Nos. 1698, 1700, 1701, 1702, 1703, 1704, 1705, 1706). Nevertheless, the Court reviewed these documents as well, almost all of which were completely irrelevant. For example, the documents include pictures from colonos-copies, EKGs, and pap smear results. The Court held oral argument on the omnibus motion on November 1, 2016, and the matter is now before the Court for a decision. B. The Court’s Daubert Rulings 1. General Causation On September 24-25, 2015, the Court heard extended oral argument on Defendant’s motions to exclude common expert witnesses, including Plaintiffs’ general causation experts. (Dkt. Nos. 1147, 1148). One of the primary issues raised both in briefing and at oral argument was the importance of dosage. Lipitor is prescribed in four different doses: 10 mg, 20 mg, 40 mg, and 80 mg. Plaintiffs’ general causation experts initially “opine[d] that Lipitor can cause diabetes, without specifying the precise dose at which this effect begins.” (Dkt. No. 1159 at 26). If a study suggested an increased risk of diabetes, the experts “ascribe[d] the risk to all doses.” (E.g., Dkt. No. 972 at 269). However, Pfizer argued that “[d]ose is critical to proving general causation,” and that Plaintiffs lacked reliable evidence that Lipitor causes diabetes at doses less than 80 mg. (Id. at 49). After reviewing the studies relied on by the experts and their opinions, the Court was concerned about whether Plaintiffs’ experts had sufficient facts and data to support their causation opinions at all doses of Lipitor, and even whether the experts would be willing to offer an opinion at low doses, given the available data. See In re Seroquel Products Liab. Litig., No. 6:06-MD-1769-ORL-22D, 2009 WL 3806434, at *18 (M.D. Fla. June 18, 2009) (Expert offering a causation opinion “declined to even speculate” about doses of 12.5 and 25 milligrams “because she had not seen any studies evaluating doses that low.”); In re Bextra & Celebrex Mktg. Sales Practices & Prod. Liab. Litig., 524 F.Supp.2d 1166, 1175-76 (N.D. Cal. 2007) (“It is unsurprising that most of plaintiffs’ experts agree that the available evidence at 200 mg/d [as opposed to higher doses] is inadequate to prove causation.”). The Plaintiffs’ experts agreed, and some even emphatically argued, that there was a dose-response relationship, meaning that any risk of diabetes is higher at higher doses of Lipitor, and the data with regard to 80 mg of Lipitor was starkly different from the data with regard to 10 mg of Lipitor. Thus, the Court ordered supplemental briefing on this issue. (Dkt. No. 1149). After a thorough review of relevant caselaw and the expert opinions at issue, the Court issued an order on October 22, 2015, holding that “at least where the experts agree that there is a dose-response relationship and where there is evidence that an association no longer holds at low doses, dose certainly matters, and Plaintiffs must have expert testimony that Lipitor causes, or is capable of causing, diabetes at particular dosages.” (CMO 49, Dkt. No. 1197 at 11). Over Defendant’s strenuous objections, the Court re-opened expert discovery and allowed additional time for Plaintiffs to serve supplemental reports offering opinions as to whether Lipitor causes diabetes at dosages of 10 mg, 20 mg, 40 mg, and 80 mg. (See id.). The parties served supplemental expert reports on general causation in December of 2015 and January of 2016, and then filed' supplemental briefs on Pfizer’s motion to exclude Plaintiffs’ general causation expert testimony in February of 2016. (See CMO 50, Dkt. No. 1230; CMO 60, Dkt. No. 1318). The Court heard additional oral argument on March 18, 2016. (Dkt. No. 1460). In a forty-page order issued on March 30, 2016, the Court ultimately excluded Plaintiffs’ expert opinions on general causation, except for the opinion of Plaintiffs’ epidemiologist, Dr. Singh, that Lipitor 80 mg causes diabetes. (CMO 68, Dkt. No. 1469). The Court found "Dr, Singh’s 10 mg opinion was not based on sufficient facts and data and that Dr. Singh did not reliably apply the epidemiological/Bradford Hill method because this method requires a statistically significant association be established through studies and such studies do not exist for Lipitor 10 mg. (Dkt. No. 1469 at 15-16). Plaintiffs conceded that Dr. Singh could not offer an opinion at Lipitor 20 mg or Lipitor 40 mg if the Court excluded his opinion regarding Lipitor 10 mg. (Id. at 24). The Court also excluded the opinions of Dr. Quon, an endocrinologist who ostensibly reached his conclusion via a literature review but who admittedly cherry-picked studies to support his conclusion rather than considering the totality of the literature, (id. at 27-34); Dr. Roberts, a cardiologist, who claimed' in her report to use the Bradford Hill method used by epidemiologists but who seemed to misunderstand the methodology’s basic premise in deposition, who cherry-picked studies for consideration and failed to consider contrary evidence, and who failed' to provide any analysis of'particular dosages as required by CMO 49, (id. at 34-38); and Dr. Gale, who faded to provide any analysis of particular dosages as required by CMO 49 and who ascribed the risk observed at Lipitor 80 mg to all dosages of Lipitor. (Id. at 38-39). Thus, the only admissible opinion on general causation is Dr. Singh’s opinion regarding Lipitor 80 mg. 2. Specific Causation Diabetes is a complicated and progressive disease, and a number of factors, including genetics, diet, exercise, age, and weight play a significant role in the development of new onset diabetes. (See, e.g., Dkt. No. 972 at 16-22, Dkt. No. 1047 at 9-12; Dkt. No. 1004-3 at 325-26). This makes teasing out the role of Lipitor, if there is one, in the development of a particular patient’s diabetes difficult. Interestingly, none of Plaintiffs’ general causation experts could think of a method to determine whether a particular patient’s diabetes was caused by Lipitor or caused by other risk factors and testified that they themselves could not determine whether a particular patient’s diabetes was caused by Lipitor. Plaintiffs’ specific causation experts have never diagnosed a patient with Lipitor-induced (or statin-induced) diabetes outside of this litigation, and they could not identify anyone else who applied their methodologies to do so outside of this litigation. Plaintiffs in this MDL are not the first to grapple with the problems of proving causation where the alleged injury is a complicated, progressive, multi-factor disease like diabetes. In Guinn v. AstraZeneca Pharm. LP, 602 F.3d 1245 (11th Cir. 2010), the plaintiff claimed that the drug Seroquel caused her to develop diabetes, and the Eleventh Circuit upheld the exclusion of her expert testimony on causation. The expert first testified that “she knew of no methodology for ruling out alternative causes [of diabetes]” and then later testified that other potential causes were “not solely responsible” because plaintiff developed diabetes after taking Seroquel and other risk factors remained constant. Id. at 1249-50. The Eleventh Circuit held that this reliance on temporal proximity did not “satisfy the requirement that a differential diagnosis consider possible alternative causes.” Id. at 1254. The Eleventh Circuit also rejected the expert’s second explanation that all risk factors work together to cause diabetes, holding that “[a]n expert ... cannot merely conclude that all risk factors for a disease are substantial contributing factors in its development.” Id. at 1255. Similarly, in Haller v. AstraZeneca Pharm. LP, 598 F.Supp.2d 1271 (M.D. Fla. 2009), the plaintiff claimed Seroquel caused her to develop diabetes. Again, plaintiffs expert could not rule out other possible causes of diabetes or the possibility that these other risk factors were solely to blame. Id. at 1278, 1278-79. The court held that temporal connection is legally insufficient and the last additive factor argument was “largely temporal proximity in disguise.” Id. at 1297-98. These same issues surfaced with Plaintiffs’ specific causation experts in this MDL. The first bellwether Plaintiff, Plaintiff Daniels, proffered the testimony of Dr. David Handshoe on the issue of specific causation. The second bellwether Plaintiff, Plaintiff Hempstead proffered the testimony of both Dr. Handshoe and Dr. Murphy on the issue of specific causation. Pfizer moved to exclude the testimony of both experts, (Dkt. Nos. 1004, 1006), and the Court held two separate days of oral argument on these motions in October and December of 2015. (Dkt. Nos. 1196, 1273). On December 11, 2015, the Court issued CMO 55, excluding the testimony of Dr. Murphy. (Dkt. No. 1283). Dr. Murphy determined that the most reliable data suggested a relative risk ratio of developing diabetes while taking Lipitor to be around 1.6. (Dkt. No. 1006-3 at 49). Using this estimate of relative risk, 63% of the people who take Lipitor and develop diabetes would have done so in the absence of Lipitor, whereas 37% of the people who take Lipitor and develop diabetes did so only because they took Lipitor. Thus, the Court turned to Dr. Murphy’s methodology for concluding that Plaintiff Hempstead was in the 37% that developed diabetes due to Lipitor, rather than the 63% that would have done so regardless. (Dkt. No. 1283 at 10). Dr. Murphy testified that Plaintiff Hempstead’s BMI, adult weight gain, family history, age, and hypertension were all significant or substantial contributing factors in Plaintiff Hempstead’s development of diabetes. (Dkt. No. 1275-2 at 185, 186, 247). Dr. Murphy’s opinion that Lipitor was also a substantial contributing factor to Plaintiff Hempstead’s development of diabetes was based on population studies showing that Lipitor increases the risk of diabetes (an element of general causation) and a temporal relationship, i.e., that Ms. Hempstead took Lipitor before developing diabetes. (See Dkt. No. 1283 at 11-15). Dr. Murphy failed to offer any explanation as to why Ms. Hempstead’s other risk factors for diabetes, alone or in combination, were not solely responsible for Ms. Hempstead’s diabetes. (Id. at 28). The Court ultimately held this data and methodology insufficient under Rule 702 and excluded the testimony, (See id.). The Court later denied Plaintiffs’ motion to reconsider its exclusion of Dr. Murphy’s testimony in CMO 75, Dkt. No. 1514. On May 11, 2016, the Court issued CMO 76, excluding the testimony of Dr. Hand-shoe in both this case and the Daniels case. Dr. Handshoe testified that the best estimate of the relative risk ratio for diabetes associated with statin use was 1.25. (Dkt. No. 1004-6 at 238-39). Using this estimate of relative risk, 80% of the people who take Lipitor and develop diabetes would have done so in the absence of Lipitor, whereas 20% of the people who take Lipitor and develop diabetes did so only because they took Lipitor. Thus, the Court turned to Dr. Handshoe’s methodology for concluding that Plaintiffs Daniels and Hempstead were in the 20% that developed diabetes due to Lipitor, rather than the 80% that would have done so regardless. (Dkt. No. 1517 at 7-8). Interestingly, Dr. Handshoe testified that if he walked into a room of 100 patients with diabetes, he could not pick out which ones would have “statin induced diabetes” as opposed to “non-statin induced diabetes.” (Dkt. No. 1004-6 at 163). He testified he could not do this with ten people or with two people. (Id.). Thus, the Court was curious how he accomplished it in the cases of Ms. Daniels and Ms. Hempstead. With regard to Ms. Hempstead, Dr. Handshoe stated that he felt her overweight BMI was “not clinically significant given that ... she had multiple normal blood sugars even with this weight.” (Dkt. No. 1004-42 at 109). He testified that he did not know whether adult weight gain increased a patient’s risk of diabetes and, therefore, did not consider it. (Dkt. No. 1004-42 at 109, 110). Dr. Handshoe acknowledged that Plaintiff Hempstead’s ethnic background and age increased her risk of diabetes but summarily dismissed these as potential causes of her diabetes based on his “clinical judgment.” (Id. at 142,144, 206-08). Dr. Handshoe simply did not consider other risk factors that he testified were independent risk factors for diabetes, such as hypertension, elevated triglycerides and low HDL. (Id. at 181, 194). In the Daniels case, Dr. Handshoe testified that the diabetes risk factors were additive: “you have this risk, you have that risk, I think the risks are additive. I mean, how can you tease out that only one thing caused’ somebody’s diabetes ...” (Dkt. No. 1004-6 at 134). However, Dr. Handshoe took the opposite position in his deposition in this case. He testified that Lipitor was “the only factor” in Ms. Hemp-stead’s development of diabetes, finding that all other factors were “not significant to my clinical judgment.” (Id. at 236, 237). He testified that his analysis was based solely on temporal relationship: Ms. Hempstead took Lipitor and developed diabetes after taking Lipitor. (Id. at 145-46). The Court excluded Dr. Handshoe’s testimony as unreliable for multiple reasons in CMO 76. (Dkt. No. 1517). C. Summary Judgment Arguments In their response to this summary judgment motion and in response to the summary judgment motions filed in the two bellwether eases on the same day in this MDL, Plaintiffs raise for the first time the argument that they can survive summary judgment on both general and specific causation without expert testimony. Plaintiffs argue that Defendant has admitted that Lipitor can cause Type 2 diabetes at doses lower than 80 mg and that these alleged admissions are competent evidence of general causation. (Dkt. No. 1586 at 15-26). With regard to specific causation, Plaintiffs argue that they may be able to survive summary judgment with some evidence other than expert testimony and argue that the Court should remand all of the cases in the MDL back to the transferor courts for those courts to take up the issue on specific causation. The Court addresses each argument in turn. II. Legal Standard Summary judgment is appropriate “if the movant shows that 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). Only material facts-those “that might affect the outcome of the suit under the governing law”—will preclude the entry of summary judgment. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). A dispute about a material fact is genuine “if the evidence is such that a reasonable jury could return a verdict for the non-moving party.” Id. At the summary judgment stage, the court must “construe the evidence, and'all reasonable inferences that may be drawn from such evidence, in the light most favorable to the nonmoving party.” Dash v. Mayweather, 731 F.3d 303, 310 (4th Cir. 2013). However, “the nonmoving party must rely on more than conclusory allegations, mere speculation, the building of one inference upon another, or the mere existence of a scintilla of evidence.” Id. at 311. Ill, Discussion Here, Defendant has moved for summary judgment on the basis that Plaintiffs have no evidence to support two essential elements of her claims—general and specific causation. “Rule 56(c) mandates the entry of summary judgment ... against a party who fails to make a showing sufficient to establish the existence of an element essential to that party’s case, and on which that party will bear the burden of proof at trial.” Celotex Corp. v. Catrett, 477 U.S. 317, 322, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). Thus, to survive summary judgment, Plaintiffs must cite to evidence in the record that would allow a jury to infer that Lipitor is capable of causing diabetes at dosages of less than 80 mg and that it did in fact cause individual Plaintiffs to develop diabetes. A. General Causation As explained above, th’e Court excluded Plaintiffs’ expert testimony on general causation with respect to dosages of less than 80 mg. (See CMO 49, Dkt. No. 1197; CMO 68, Dkt. No. 1469). Because Plaintiffs at issue here were prescribed and ingested Lipitor is dosages of less than 80 mg prior to their diabetes diagnosis, they have no admissible expert testimony regarding general causation. However, Plaintiffs argue that alleged admissions by Defendant are sufficient to survive summary judgment. Specifically, Plaintiffs argue that four pieces of evidence constitute admissions by Defendant that Lipitor can cause diabetes at dosages less than 80 mg: (1) An email from Senior Vice President David DeMicco; (2) the U.S. Lipitor label stating that “[ijncreases in HbAlc and fasting serum glucose levels have ^ been reported with [statins], including LIP-ITOR”;- (3) Parke-Davis’s New Drug Application (NDA) data showing that Lipitor was associated with increases in blood glucose levels; (4) The official Lipitor website, which states that “[e]levated blood sugar levels have been reported with sta-tins, including LIPITOR”; and (5) Pfizer’s Japanese label insert for Lipitor. (Dkt. No. 1586 at 16). Plaintiffs argue that these pieces of evidence are admissible under Rule 801(d)(2) for the truth of the matter asserted. Except for the Japanese label, Pfizer does not dispute the admissibility of the evidence put forward by Plaintiffs. Pfizer, however, does dispute that this evidence is sufficient to survive summary judgment in the absence of expert testimony. 1. Eñe Question Plaintiffs generally argue that state substantive law controls whether expert evidence of causation is needed to survive summary judgment in products liability cases. (Dkt. No. 1586 at 26-35). However, Plaintiffs also argue that state law does not control whether expert evidence of causation is needed to survive summary judgment if the non-expert evidence of causation at issue is a party opponent admission under Rule 801(d)(2). (Dkt. No. 1634 at 32-33). In the specific instance where non-expert testimony of causation consists of a party opponent admission, Plaintiffs argue that Rule 56 supersedes state law and requires denial of summary judgment. (Id.). Plaintiffs cannot have it both ways. Either Rule 56 supersedes any state law on what type of evidence is sufficient to survive summary judgment or substantive state law governs whether expert testimony is required to survive summary judgment.-Thus, the Court first addresses whether federal or state law controls this question under Eñe. “Under the familiar Eñe doctrine, [courts] apply state substantive law and federal procedural law when' reviewing state-law claims.” Kerr v. Marshall Univ. Bd. of Governors, 824 F.3d 62, 74 (4th Cir. 2016). To the extent that Plaintiffs argue that the standard of Federal Rule of Civil Procedure 56 applies to the claims at issue, they are clearly correct. See Jones v. Meat Packers Equip. Co., 723 F.2d 370, 372 (4th Cir. 1983) (“A federal standard determines the sufficiency of the evidence for submission of an issue to a jury.”); Fitzgerald v. Manning, 679 F.2d 341, 346 (4th Cir. 1982) (“[W]hether there is sufficient evidence to create a jury issue of those essential substantive elements of the action, as defined by state law, is controlled by federal rules.”); Millers Mut. Ins. Ass’n of Ill. v. S. Ry. Corp., 483 F.2d 1044, 1046 (4th Cir. 1973) (“We apply a federal standard to determine whether the plaintiffs case presented a jury question.”). However, this is not the end of the inquiry. The substantive elements of a state claim, including the applicable standard of care, whether the standard has been violated, and whether the alleged violation is the cause of a plaintiff’s injury, are all questions determined by state law when a court sits in diversity. Fitzgerald, 679 F.2d at 346. And a number of federal courts sitting in diversity have held that whether a plaintiff must offer admissible expert testimony regarding medical causation in complex products liability cases is a matter of substantive state law because such a rule is part of the substantive element of causation. See, e.g., In re Mirena IUD Prod. Liab. Litig., No. 13-MC-2434 (CS), 202 F.Supp.3d 304, 314, 2016 WL 4059224, at *8 (S.D.N.Y. July 28, 2016) (“[T]he issue here is not so much whether the alleged admissions are admissible against [defendant] as a matter of the law of evidence, but whether as a matter of substantive products liability law admissions can substitute for expert evidence of causation, given the widely held principle that expert testimony is required in cases involving a complex or technical question outside the ken of the average lay juror.”); Silverman v. Watson Pharm., Inc., No. CIV.A. H-10-1952, 2013 WL 1645771, at *2 (S.D. Tex. Apr. 16, 2013) (“[Defendant] asks the court to conflate federal procedural law governing the admissibility of expert testimony with Texas substantive law regarding the levels of proof required to demonstrate causation in a toxic tort case”). In other words, while the question of whether evidence is sufficient to survive summary judgment is generally a matter of federal procedural law, “the ‘expert testimony’ rule” may be “so closely interrelated with the substantive cause of action ... that federal courts sitting in diversity cases should apply the state rule in order to fully realize state substantive policy.” Hemingway v. Ochsner Clinic, 722 F.2d 1220, 1225 (5th Cir. 1984); see also Milam v. State Farm Mut. Auto. Ins. Co., 972 F.2d 166, 170 (7th Cir. 1992) (“[W]here a state in furtherance of its substantive policy makes it more difficult to prove a particular type of state-law claim, the rule by which it does this, even if denominated a rule of evidence or cast in evidentiary terms, will be given effect in a diversity suit as an expression of state substantive policy.”); Burke v. Air Serv Int’l, Inc., 685 F.3d 1102, 1109 (D.C. Cir. 2012) (“[S]tate law controls where it makes a precondition to recovery in a medical-malpractice action the proffer of expert testimony to prove an element of the substantive-law claim, such as standard of care or causation.”) (quoting 9 Charles Alan Wright & Victor James Gold, Federal Practice & Procedure: Evidence § 6263, at 204 (1997)); Bryte ex rel. Bryte v. Am. Household, Inc., 429 F.3d 469, 476 (4th Cir. 2005) (noting the difference between “a procedural rule governing admissibility” of expert testimony and “substantive state rules on the sufficiency of evidence”). Like other federal courts that have addressed the issue, this Court finds that a state law requirement that expert testimony is necessary to establish a particular element of a eause of action, such as causation, is a statement of'state substantive policy, “intimately bound up with the state right or obligation.” DiAntonio v. Northampton-Accomack Mem’l Hosp., 628 F.2d 287, 291 (4th Cir. 1980) (quoting Szantay v. Beech Aircraft Corp., 349 F.2d 60, 63 (4th Cir. 1966)). Because such a rule defines and limits the primary rights and obligations of the parties, it “must be applied under the Erie doctrine.” Mattison v. Dallas Carrier Corp., 947 F.2d 95, 109 (4th Cir. 1991). To the extent that state substantive law requires causation to be established by expert testimony, it is also a question of state substantive law whether party-opponent admissions can substitute for expert evidence of causation. In re Mirena, 202 F.Supp.3d at 314, 2016 WL 4059224 at *8. However, as explained more fully below, the argument that party-opponent admissions can substitute for expert evidence is a recent and novel one created by plaintiffs in multi-district litigations where expert evidence has been excluded under Daubert. Thus, the state courts have not had an opportunity to pass on the specific question, and the Court must “predict what the Supreme Court of [various states] would decide.” Doe v. Doe, 973 F.2d 237, 240 (4th Cir. 1992). In doing so, the Court is guided by the Fourth Circuit’s admonition that “a federal court in the exercise of its diversity jurisdiction should act conservatively when asked to predict how a state court would proceed on a novel issue of state law,” Rhodes v. E.I. du Pont de Nemours & Co., 636 F.3d 88, 97-98 (4th Cir. 2011), and the few federal cases that address the issue. 2, Expert Testimony is Required Under State Substantive Law. As an initial matter, Plaintiffs dispute whether state substantive law requires expert testimony in this instance. Plaintiffs argue that state law “reflects a spectrum of subtly varying rules” that ranges from the requirement of expert testimony to no requirement at all. (Dkt. No. 1586 at 27). The variance is not nearly as great as Plaintiffs would have the Court believe. While the specific language used by courts vary to some degree, all jurisdictions require expert testimony at least where the issues are medically complex and outside common knowledge and lay experience. See, e.g., Ex parte Trinity Indus., Inc., 680 So.2d 262, 269 (Ala. 1996) (expert testimony required to establish causation where “the nature and origin” of the injury is “beyond the understanding of the average person”); E.C. ex rel. Crocker v. Child Dev. Sch., Inc., No. 3:10-CV-759-WKW, 2011 WL 4501560, at *9 (M.D. Ala. Sept. 29, 2011) (“[E]xpert medical testimony, and not lay testimony, is required to demonstrate proximate cause, given the complexity of E.C.’s heart. condition.”); Choi v. Anvil, 32 P.3d 1, 3 (Alaska 2001) (expert testimony required to establish a causal connection “where there is no reasonably apparent ... causal relationship between the event demonstrated and the result sought to be proved”); Voyles v. State, No. A-9377, 2008 WL 4951416, at *18 (Alaska Ct. App. Nov. 19, 2008) (“The test is whether the basis of the [casual] conclusion (once explained) can be readily understood and assessed by lay juror’s.”); Rasor v. Nw. Hosp., LLC, 239 Ariz. 546, 373 P.3d 563, 566 (Ariz. Ct. App. 2016) (expert testimony required to establish causation “unless a causal relationship is readily apparent to the trier of fact”); Gentry v. Daughenty, No. CV-13-02136PHX-ESW, 2015 WL 1346097, at *3 (D. Ariz. Mar. 24, 2015) (“Unless an injury is obvious to the jury, expert medical testimony is required to establish the nature and extent of the injury as well as its relationship to the accident.”) (citing Arizona cases); Isham v. Booneville Cmty. Hosp., No. 2:14-CV-2018, 2015 WL 4133098, at *2 (W.D. Ark. July 8, 2015) (“Under Arkansas law, expert witness testimony is required to prove that any negligence of Defendants was a proximate cause of Plaintiffs injuries, as Plaintiff in this case alleged medical injuries based on a theory that involved complex determinations of medical issues that would not and could not be commonly understood by a lay person.”); Richardson v. Union Pac. R. Co., 386 S.W.3d 77, 80 (Ark. App. Ct. 2011) (“[Wlhen there is no obvious origin to an injury and it has multiple potential etiologies, expert testimony is necessary to establish causation.”); Miranda v. Bomel Const. Co., 187 Cal.App.4th 1326, 115 Cal.Rptr.3d 538, 545-46 (2010) (“The law is well settled that in a personal injury action causation must be proven within a reasonable medical probability based upon competent expert testimony.”); Sclafani v. Air & Liquid Sys. Corp., 14 F.Supp.3d 1351, 1355 (C.D. Cal. 2014) (“Under California law, although juries are normally permitted to decide issues of causation without guidance from experts,” issues of causation “beyond the experience of laymen and can only be explained through expert testimony.”); Howell v. Centric Grp., LLC, No. 09-CV-02299-MSK-CBS, 2011 WL 4499372, at *5 (D. Colo. Sept. 27, 2011) (“Although causation may sometimes be inferred simply from circumstantial evidence, where questions of causation are beyond the knowledge and experience of ordinary persons, expert testimony may be required”) (applying Colorado law), aff'd, 508 Fed.Appx. 834 (10th Cir. 2013); Xtreme Coil Drilling Corp. v. Encana Oil & Gas (USA), Inc., No. CIV.A. 08-CV-02750, 2010 WL 3777303, at *7 (D. Colo. Sept. 19, 2010) (“Under Colorado law, products-liability claims involving matters outside the experience of the average layperson, like negligence claims involving such complex or technical issues, require expert testimony to prove issues such as causation.”); Metro. Prop. & Cas. Ins. Co. v. Deere & Co., 302 Conn. 123, 25 A.3d 571, 584 (2011) (“If lay witnesses and common experience are not sufficient to remove the case from the realm of speculation, the plaintiff will need to present expert testimony to establish a prima facie case.”); White v. Mazda Motor of Am., Inc., 139 Conn.App. 39, 54 A.3d 643, 650 (2012) (“[W]e ... consistently have held that expert testimony is required when the question involved goes beyond the field of the ordinary knowledge and experience of judges or jurors.”) (internal quotations omitted), aff'd, 313 Conn. 610, 99 A.3d 1079 (2014); Roache v. Charney, 38 A.3d 281, 286 (Del. 2012) (“When the plaintiffs claim involves bodily injuries, the causal connection between the defendant’s alleged negligent conduct- and the plaintiffs alleged injury must be proven by the direct testimony of a competent medical expert.”); Money v. Manville Corp. Asbestos Disease Comp. Trust Fund, 596 A.2d 1372, 1375 (Del. 1991) (“[I]f the matter in issue is one within the knowledge of experts only and not within the common knowledge of laymen, it is necessary for the plaintiff to introduce expert testimony in order to establish a prima facie case.”) (internal quotations omitted); Lasley v. Georgetown Univ., 688 A.2d 1381, 1385 (D.C. 1997) (“Expert testimony is not required if the issue of causation can be resolved wholly within the realm of ordinary human knowledge and experience ... or if the proof is so obvious as to lie within the ken of the average lay juror.”) (internal quotations omitted); Baltimore v. B.F. Goodrich Co., 545 A.2d 1228, 1231 (D.C. 1988) (expert testimony required “in cases presenting medically complicated questions due to multiple and/or preexisting causes”); Benitez v. Joseph Trucking, Inc., 68 So.3d 428, 431 (Fla. Dist. Ct. App. 2011) (expert testimony is necessary “to establish legal causation where the issue is beyond the common knowledge of laymen”); Gouveia v. Phillips, 823 So.2d 215, 227 (Fla. Dist. Ct. App. 2002) (expert testimony required “when the discrete issue to be decided is not within the abilities of lay jurors”); Cowart v. Widener, 287 Ga. 622, 697 S.E.2d 779, 784 (2010) (expert testimony required “where the existence of a causal link between the defendant’s conduct and the plaintiffs injury cannot be determined from common knowledge and experience and instead requires the assistance of experts with specialized medical knowledge.”); Gilbert v. R.J. Taylor Mem’l Hosp., Inc., 265 Ga. 580, 458 S.E.2d 341, 342 n.4 (1995) (“Although it is Conceded that the cause of action is one for simple negligence, rather than for professional malpractice, medical questions are raised, requiring expert evidence.”); Barbee v. Queen’s Med. Ctr., 119 Hawai’i 136, 194 P.3d 1098, 1121 (Haw. Ct. App. 2008) (“Hawai’i does recognize a ‘common knowledge’ exception to the requirement that a plaintiff must introduce expert medical testimony on causation .... The exception is similar to the doctrine of res ipsa loquitur, and ... rare in application.”) (internal quotations omitted); Bernard v. Char, 79 Hawai’i 371, 903 P.2d 676, 682 (Haw. Ct. App.) (expert testimony required where “lay jurors are ill prepared to evaluate complicated technical data for the purpose of determining ... whether there is a causal relationship between the violation of a duty and an injury to the patient”), aff'd, 79 Hawai’i 362, 903 P.2d 667 (1995); Easterling v. Kendall, 159 Idaho 902, 367 P.3d 1214, 1226 (2016) (expert testimony required where “the causative factors are not ordinarily within the knowledge or experience of laymen composing the jury”), reh’g denied (Mar. 31, 2016); Dodge-Farrar v. Am. Cleaning Servs. Co., 137 Idaho 838, 54 P.3d 954, 959 (Idaho Ct. App. 2002) (expert, testimony required where the matter is not within “the usual and ordinary experience of the average person”); Brown v. Baker, 284 Ill.App.3d 401, 219 Ill.Dec. 754, 672 N.E.2d 69, 71 (1996) (“[A] plaintiff in a personal injury case must present the testimony of a medical expert to establish causation if the relationship between the claimed injury and the event in question requires special knowledge and training to establish.”); Willis v. Westerfield, 839 N.E.2d 1179, 1188 (Ind. 2006) (“[Ejxpert testimony is required where the question involves medical factors beyond the common knowledge of the layman.”); Topp v. Leffers, 838 N.E.2d 1027, 1035 (Ind. Ct. App. 2005) (expert testimony not required “[w]hen the issue of causation is within the understanding of a lay person.”); Welte v. Bello, 482 N.W.2d 437, 441 (Iowa 1992) (expert testimony not required when causation is “within the common experience of laypersons”); Donovan v. State, 445 N.W.2d 763, 766 (Iowa 1989) (“[Hjighly technical questions of diagnoses and causation which lie beyond the understanding of a layperson require introduction of expert testimony.”); Pope By & For Juby v. Ransdell, 251 Kan. 112, 833 P.2d 965, 973 (1992) (“Expert testimony is necessary where normal experience and qualifications of lay persons serving as jurors does not permit them to draw proper conclusions from the facts and circumstances of the case.”); Azmat v. Bauer, No. 2015-CA-000399-MR, 2016 WL 4709135, at *3 (Ky. Ct. App. Sept. 9, 2016) (expert testimony required in medical negligence case “in instances where causation is not so obvious as to amount to res ipsa loqui-tur”); Wilson v. Thyssenkrupp Budd Co., No. 2005-CA-001567-WC, 2005 WL 3116045, at *3 (Ky. Ct. App. Nov. 23, 2005) (“When the cause of a condition is not readily apparent to a lay person, med ical testimony supporting causation is required.”); Burgett v. Troy-Bilt LLC, 970 F.Supp.2d 676, 683 (E.D. Ky. 2013) (expert testimony required for topics “beyond the ken of ordinary persons”), aff'd, 579 Fed.Appx. 372 (6th Cir. 2014); Johnson v. E.I. DuPont deNemours & Co., 7 So.3d 734, 740 (La. App. 5 Cir. 2009) (“When a conclusion regarding medical causation is not one within common knowledge, expert medical testimony is required in a tort action.”); Hutchinson v. Shah, 648 So.2d 451, 452, (La. App. 1 Cir. 1994) (“When the conclusion regarding medical causation is not one within common knowledge, expert medical testimony is required.”), writ denied 653 So.2d 570 (La. 1995); Darney v. Dragon Prod. Co., LLC, 640 F.Supp.2d 117, 123 (D. Me. 2009) (“[A] jury may not ‘infer causation on complex medical facts without the aid of expert testimony.’ ”) (quoting Merriam v. Wanger, 757 A.2d 778, 782 (Me. 2000)); Walter v. Wal-Mart Stores, Inc., 748 A.2d 961, 972 (Me. 2000) (expert testimony not required where the “harmful results” of a negligent act “are sufficiently obvious as to lie within common knowledge”); Wood v. Toyota Motor Corp., 134 Md.App. 512, 760 A.2d 315, 319 (Md. Ct. Spec. App. 2000) (“It is well settled that expert testimony is required when the subject of the inference is so particularly related to some science or profession that it is beyond the ken of the average layman.”) (internal quotations omitted); Miskin v. Baxter Healthcare Corp., 107 F.Supp.2d 669, 672 (D. Md. 1999) (expert testimony is necessary under Maryland law when “the evidence relating to causation involves technical medical questions beyond the common knowledge of laypersons”), aff'd, 213 F.3d 632 (4th Cir. 2000) (table decision); Case of Canavan, 432 Mass. 304, 733 N.E.2d 1042, 1051 (2000) (“Because understanding medical causation is beyond the knowledge of the ordinary layman proof of if it must rest upon expert medical testimony.”) (internal quotations and alterations omitted); Pitts v. Wingate At Brighton, Inc., 82 Mass.App.Ct. 285, 972 N.E.2d 74, 78 (2012) (“Expert testimony is necessary where proof of medical causation lies outside the ken of lay jurors.”); Hendrian v. Safety-Kleen Sys., Inc., No. 08-CV-14371, 2015 WL 4770966, at *4 (E.D. Mich. Aug. 13, 2015) (“[E]x-pert testimony is often required because the alleged injuries are not immediately obvious and the connection between exposure and injury is not a matter of common sense or everyday experience.”) (internal quotations omitted); Dow v. Rheem Mfg. Co., No. 09-13697-BC, 2011 WL 4484001, at *22 (E.D. Mich. Sept. 26, 2011) (“Though not always required, expert testimony on causation is necessary, where the claim presents ‘technical issues that are beyond the common experience and understanding of the common juror.’”) (quoting Schaendorf v. Consumers Energy Co., No. 281001, 2009 WL 563904, at *7-8 (Mich. Ct. App., March 5, 2009)), aff'd, 527 Fed.Appx. 434 (6th Cir. 2013); Gross v. Victoria Station Farms, Inc., 578 N.W.2d 757, 762 (Minn. 1998) (“Expert opinion is required to prove causation if the issue is outside the realm of common knowledge.”); Walton v. Jones, 286 N.W.2d 710, 715 (Minn. 1979) (“[W]hen the causal relation issue is not one within the common knowledge of laymen, causation in fact cannot be determined- without expert testimony.”) (quotation omitted); Denham v. Holmes ex rel. Holmes, 60 So.3d 773, 789 (Miss. 2011) (“Expert testimony is required unless the matter in issue is within the common knowledge of laymen”) (quoting Palmer v. Biloxi Reg’l Med. Ctr., Inc., 564 So.2d 1346, 1355 (Miss. 1990)); Berry v. Sw. Airlines Co., No. CIVA 307CV305TSL-JCS, 2008 WL 3874368, at *2 (S.D. Miss. Aug. 15, 2008) (‘While in less complex cases where causation may be understood with only common sense, causation may be proved by lay testimony alone; however, with injuries that are medically complicated ... expert testimony is required to prove causation.”); Wright v. Barr, 62 S.W.3d 509, 524 (Mo. Ct. App. 2001) (“If there is a sophisticated injury, one that requires surgical intervention or other highly scientific techniques for diagnosis, expert medical testimony is required to prove causation.”); Pro Serv. Auto., L.L.C. v. Lenan Corp., 469 F.3d 1210, 1214 (8th Cir. 2006) (holding that under Missouri law, “expert testimony is necessary where the lay jury does not possess the experience or knowledge of the subject matter sufficient to enable them to reach an intelligent opinion without help”) (internal quotations and alteration omitted); Hinkle v. Shepherd Sch. Dist. No. 37, 322 Mont. 80, 93 P.3d 1239, 1246 (2004) (“[Ejxpert testimony is required when the issue presented is sufficiently beyond the common experience of the trier of fact and the expert testimony will assist the trier of fact in determining the issue or understanding the evidence.”); Moralli v. Lake Cty., Monk, 255 Mont. 23, 839 P.2d 1287, 1291 (1992) (expert testimony required in personal injury cases unless “the nature of th