                       PUBLISHED


UNITED STATES COURT OF APPEALS
             FOR THE FOURTH CIRCUIT


SHERRY ANN WALKER, Individually       
and as Administratrix of the Estate
of Arnold Leroy Walker, Jr.,
               Plaintiff-Appellant,
                v.

                                      
MEDTRONIC, INCORPORATED, a
Minnesota corporation,                      No. 10-2219
              Defendant-Appellee,
               and
MEDTRONIC USA, INCORPORATED, a
Minnesota corporation,
                        Defendant.
                                      
       Appeal from the United States District Court
 for the Southern District of West Virginia, at Charleston.
          David A. Faber, Senior District Judge.
                     (2:07-cv-00317)

                Argued: November 8, 2011

                Decided: January 25, 2012

  Before DUNCAN, WYNN, and DIAZ, Circuit Judges.



Affirmed by published opinion. Judge Duncan wrote the
majority opinion, in which Judge Diaz joined. Judge Wynn
wrote a dissenting opinion.
2                 WALKER v. MEDTRONIC, INC.
                         COUNSEL

ARGUED: Christopher Brinkley, MASTERS LAW FIRM,
LC, Charleston, West Virginia, for Appellant. Andrew E.
Tauber, MAYER BROWN, LLP, Washington, D.C., for
Appellee. ON BRIEF: David M. Gossett, Brette L. Steele,
MAYER BROWN, LLP, Washington, D.C., for Appellee.


                         OPINION

DUNCAN, Circuit Judge:

   Appellant Sherry Walker appeals from the district court’s
holding that her common law tort claims against Medtronic,
Inc. are preempted by the Medical Device Amendments of
1976 ("MDA"), as interpreted by Riegel v. Medtronic, Inc.,
552 U.S. 312 (2008). Walker argues that, because the device
in question allegedly failed to operate in accordance with the
terms of its premarket approval, her claims parallel federal
requirements and therefore should avoid preemption. In light
of Walker’s concession that the device was designed, manu-
factured, and distributed in compliance with the terms of its
premarket approval, given by the Food and Drug Administra-
tion ("FDA") as required under the MDA, however, we are
compelled to affirm.

   The exclusive provisions of the FDA regulatory process
recognize only one mechanism for the creation of an enforce-
able requirement governing the ongoing performance of a
medical device, and that is through the establishment of a for-
mal performance standard. Walker concedes that no such per-
formance standard was created here. This concession makes
clear that her common law claims seek to impose require-
ments above and beyond those of the FDA, thus bringing
them within the category expressly preempted by the MDA.
To hold otherwise would be to undermine the balance Con-
                  WALKER v. MEDTRONIC, INC.                   3
gress struck when it enacted the MDA, in which it determined
that the benefit to the many of bringing potentially lifesaving,
but risky, medical devices to the public following the rigorous
process of FDA approval outweighed the cost to the few of
preempting common law claims based on different standards.

                               I.

                              A.

   In 1976, Congress passed the Medical Device Amend-
ments, 21 U.S.C. § 360c et seq., in order to "impose[ ] a
regime of detailed federal oversight" to govern medical
devices. Riegel, 552 U.S. at 316. It did so in response to
mounting concern following the highly publicized contro-
versy surrounding the Dalkon Shield intrauterine device,
which "demonstrated the inability of the common law tort
system to manage the risks associated with dangerous
devices." Id. at 315. As such, Congress intentionally "swept
back some state obligations" in favor of uniform federal regu-
lation. Id. at 316.

  To that end, the MDA includes a provision expressly pre-
empting state regulation of medical devices. It states in rele-
vant part:

    [N]o State or political subdivision of a State may
    establish or continue in effect with respect to a
    device intended for human use any requirement—

    (1) which is different from, or in addition to, any
    requirement applicable under this chapter to the
    device, and

    (2) which relates to the safety or effectiveness of the
    device or to any other matter included in a require-
    ment applicable to the device under this chapter.
4                 WALKER v. MEDTRONIC, INC.
21 U.S.C. § 360k(a).

   The MDA also establishes three classes of medical devices,
organized according to the level of oversight required to
ensure their safety. Class I devices are those for which general
controls, such as labeling requirements, "are sufficient to pro-
vide reasonable assurance of [their] safety and effectiveness."
21 U.S.C. § 360c(a)(1)(A)(i). They include such things as
"elastic bandages and examination gloves" and are "subject to
the lowest level of oversight." Riegel, 552 U.S. at 316. Class
II devices include "such devices as powered wheelchairs and
surgical drapes," id., and are subject to heightened oversight
mechanisms, such as "performance standards [and] postmar-
ket surveillance," 21 U.S.C. § 360c(a)(1)(B).

   Class III devices require the highest level of federal over-
sight. Class III devices are those for which the general con-
trols regulating Class I devices and the specific controls that
regulate Class II devices are deemed insufficient to ensure
safety and effectiveness, and that are either useful in "support-
ing or sustaining human life or for a use which is of substan-
tial importance in preventing impairment of human health" or
that "present[ ] a potential unreasonable risk of illness or
injury." Id. at § 360c(a)(1)(C). Because of the risks associated
with them, Class III devices are required to go through pre-
market approval "to provide reasonable assurance of [their]
safety and effectiveness." Id.

   "Premarket approval is a rigorous process." Riegel, 552
U.S. at 317 (internal quotation marks omitted). To obtain pre-
market approval, a device manufacturer must submit to the
FDA full reports of all investigations relating to the device’s
safety or effectiveness; a "full statement of the components,
ingredients, and properties and of the principle or principles
of operation" of the device; a full description of the manufac-
turing methods and the facilities and controls used for the
device’s manufacturing; references to any performance stan-
dards applicable to the device; samples of the device and any
                     WALKER v. MEDTRONIC, INC.                          5
component parts; examples of the proposed labeling for the
device; and other information as requested. 21 U.S.C.
§ 360e(c)(1). This typically requires a "multivolume applica-
tion." Riegel, 552 U.S. at 317.

   The FDA reviews these applications, approving only those
it has determined provide reasonable assurance of a device’s
safety and effectiveness. It "spends an average of 1,200 hours
reviewing each application." Id. at 318. If the FDA deems it
necessary, it may refer an application to a panel of experts
"for study and for submission . . . of a report and recommen-
dation respecting approval of the application, together with all
underlying data and the reasons or basis for the recommenda-
tion." 21 U.S.C. § 360e(c)(3). The FDA’s final grant of pre-
market approval is based on "weighing any probable benefit
to health from the use of [a] device against any probable risk
of injury or illness from such use." Id. at § 360c(a)(2)(C). "It
may thus approve devices that present great risks if they none-
theless offer great benefits in light of available alternatives."
Riegel, 552 U.S. at 318.

   The FDA may condition its grant of premarket approval
upon certain requirements. Significantly for our purposes, the
FDA may require that a device meet certain performance
standards if it "determines that a performance standard is nec-
essary to provide reasonable assurance of the safety and effec-
tiveness of the device." 21 U.S.C. § 360d(a)(1).

   The establishment of a performance standard is a formal
process specifically governed by the MDA. It requires publi-
cation of a notice of proposed rulemaking in the Federal Reg-
ister setting forth justification why the performance standard
is necessary, "proposed findings with respect to the risk of ill-
ness or injury that the performance standard is intended to
reduce or eliminate," and invitation for comments from inter-
ested persons.1 Id. at § 360d(b)(1)(B). Following the expira-
   1
     The FDA may also "recognize . . . an appropriate standard established
by a nationally or internationally recognized standard development organi-
zation" by publishing such a standard in the Federal Register. 21 U.S.C.
§ 360d(c)(1)(A).
6                 WALKER v. MEDTRONIC, INC.
tion of the comment period and consideration of the
comments submitted therein, the FDA must promulgate a reg-
ulation establishing a formal performance standard and pub-
lish it in the Federal Register. Id. at § 360d(b)(3)(A). When
the FDA establishes a performance standard for a Class III
device, it does so as a precursor to the grant of premarket
approval. 21 C.F.R. § 861.1(b)(3).

   Once premarket approval has been granted, "the MDA for-
bids the manufacturer to make, without FDA permission,
changes in design specifications, manufacturing process,
labeling, or any other attribute, that would affect safety or
effectiveness." Riegel, 552 U.S. at 319. To gain FDA
approval of a proposed change, the manufacturer must submit
a supplemental application describing the change in detail and
summarizing the findings supporting the change. 21 U.S.C.
§ 360e(d)(6)(A)(i). A premarket approval application supple-
ment is "evaluated under largely the same criteria as an initial
application." Riegel, 552 U.S. at 319.

   The FDA continues to oversee Class III devices after the
grant of premarket approval. Manufacturers must report to the
FDA when an approved device "may have caused or contrib-
uted to a death or serious injury" or malfunctioned in a way
that would make it likely to do so in the future. 21 U.S.C.
§ 360i(a)(1). They also must periodically inform the FDA
about data from clinical studies or scientific literature related
to the device. 21 C.F.R. § 814.84(b). "The FDA has the power
to withdraw premarket approval based on newly reported data
or existing information and must withdraw approval if it
determines that a device is unsafe or ineffective under the
conditions in its labeling." Riegel, 552 U.S. at 319-20.

                               B.

  The device at issue here is a Model 8627-18 SynchroMed
EL Programmable Pump (the "SynchroMed pump"), which
was designed, manufactured, and distributed by Medtronic.
                   WALKER v. MEDTRONIC, INC.                    7
The SynchroMed pump is a component part of the Syn-
chroMed Infusion System, a method of delivering medication
designed for patients who require chronic infusions of drugs.
Specifically, the system delivers medication directly into the
space surrounding the spinal cord. It accomplishes this
through implantation of the SynchroMed pump in the
patient’s abdominal area and implantation of a catheter in the
patient’s interspinal space. The SynchroMed pump is con-
nected to the catheter and programmed to deliver a controlled
amount of medication at the dosage and frequency prescribed
by a physician.

   The SynchroMed pump is undisputedly a Class III device
with respect to which the FDA granted premarket approval.
The FDA originally approved Medtronic’s application for the
SynchroMed pump in 1988; it subsequently granted premar-
ket approval to application supplements in 1994 and 1999. It
is further undisputed that neither the FDA’s initial grant of
premarket approval nor its later approvals of supplemental
applications were subject to any requirement that the Syn-
chroMed pump comply with a formal performance standard
pursuant to § 360d.

   In relevant part, the FDA’s March 18, 1999 approval letter
stated that the SynchroMed pump had been modified by "ex-
tend[ing] down" the flow range "to 0.048 ml/day from 0.098
ml/day, while maintaining the delivery accuracy of ±15%."
J.A. 93. It also noted the "[c]hange to the labeling for . . . new
delivery accuracy (0.048 ml±15%)." Id.

   The Technical Manual for the SynchroMed pump—which
was approved by the FDA during the premarket approval pro-
cess and is distributed along with the device—likewise speci-
fied that "[t]he flow accuracy of the SynchroMed EL pump,
measured at the catheter tip, is within ±15 percent of the pro-
grammed flow rate." J.A. 153. It qualified this statement,
however: "[T]he accuracy of the SynchroMed EL Infusion
System depends on how closely procedures are followed.
8                 WALKER v. MEDTRONIC, INC.
Noncompliance with implant and refill procedures, as well as
other human factors, may cause the observed accuracy of the
system to vary by ±25 percent." Id.

   The Technical Manual contained other warnings about the
risks associated with use of the SynchroMed pump. Of signif-
icance here, it stated:

    Improper use of implanted, programmable infusion
    pumps could result in drug overdose. Users must
    comply with product instructions for initial pump
    preparation, programming, implantation, initial fill-
    ing, refilling, and injecting into the side catheter
    access port (if present) of the pump. Technical errors
    may result in a return of underlying symptoms, drug
    withdrawal symptoms, or a clinically significant or
    fatal drug overdose.

J.A. 107. It further noted that possible pump complications
included a "[c]hange in flow performance characteristics, due
to component failure or changes over time, which may result
in . . . overinfusion of the drug [or] drug overdose." J.A. 109.
Finally, it included the following special notice:

    The pump and catheter are implanted in the
    extremely hostile environment of the human body.
    This environment places severe demands on their
    design and function. . . . Reasons for failure of the
    pump or catheter include, but are not limited to:
    body rejection phenomena; change in performance
    characteristics due to component changes or failures;
    unusual physiological variations in patients; medical
    complications; complete or partial catheter occlu-
    sion; catheter dislodgement; catheter leakage; cathe-
    ter breakage; migration; or erosion of the pump. In
    addition, despite the exercise of all due care in
    design, component selection, manufacture, and test-
    ing prior to sale, the pump and catheters may be
                     WALKER v. MEDTRONIC, INC.                           9
      damaged before, during, or after implantation by
      improper handling or filling; by drugs or uses not
      described in this technical manual; or by other inter-
      vening acts. Consequently, no representation or war-
      ranty is made that failure or cessation of function of
      the pump or catheters will not occur, or that the body
      will not react adversely to their implantation.

J.A. 114.

                                    C.

   In May 2003, physicians implanted the SynchroMed pump
in Arnold Walker, appellant Sherry Walker’s late husband, for
the purpose of delivering medication to treat his chronic back
pain. It is undisputed that the pump functioned for approxi-
mately two years.

   On June 9, 2005, Arnold died from—according to his death
certificate—"[c]ombined hydromorphone, hydrocodone,
diazepam, and venlafaxine intoxication."2 J.A. 29. During
Arnold’s autopsy, the SynchroMed pump was removed and
placed in a bag, where it continued to dispense hydromor-
phone. Walker’s expert, Dr. Harry Milman, later analyzed the
contents of the pump and the bag and concluded that, based
on the programmed hourly infusion rate at which the medica-
tion was to be dispensed, 568 mg of hydromorphone were
unaccounted for. Milman opined that, prior to Arnold’s death,
the SynchroMed pump had malfunctioned and overinfused
the unaccounted for hydromorphone into Arnold’s body. He
concluded that this overinfusion by the SynchroMed pump
was the cause of death.3
  2
     At the time of Arnold’s death, he was being treated orally with hydro-
codone, diazepam, and venlafaxine. The only medication he was receiving
via the SynchroMed Infusion System was hydromorphone.
   3
     Medtronic vigorously contests Walker’s theory that an overinfusion by
the SynchroMed pump caused her husband’s death. It recognizes, how-
10                    WALKER v. MEDTRONIC, INC.
                                     D.

   On May 18, 2007, Walker filed a diversity suit against
Medtronic in the United States District Court for the Southern
District of West Virginia. She alleged that the SynchroMed
pump had malfunctioned, resulting in Arnold’s death from a
lethal overdose of medication. In her complaint, she asserted
three common law causes of action: negligence, strict liabil-
ity, and breach of warranty. She sought compensatory and
punitive damages, attorney’s fees, costs, and pre- and post-
judgment interest.

   On April 21, 2008, following the Supreme Court’s decision
in Riegel, Medtronic moved for summary judgment, arguing
that Walker’s claims were preempted. The district court
denied the motion without prejudice, finding that there was a
dispute of fact regarding whether the SynchroMed pump in
question complied with the terms of its premarket approval.
The court recognized, however, that Walker’s original com-
plaint did not allege a claim that would survive Riegel’s pre-
emption analysis. Consequently, it informed her that she
could amend the complaint to correct the deficiency.

   Walker filed an amended complaint on October 29, 2008.
In her amended complaint, she asserted the same three causes
of action but alleged for the first time that "the pump failed
to comply and operate in terms of its Pre-Market Approval."
J.A. 40.

   The parties then engaged in discovery to determine whether
the SynchroMed pump complied with the terms of is premar-

ever, that this factual dispute is irrelevant to the question of whether Walk-
er’s claims are preempted by the MDA. Because when reviewing a grant
of summary judgment, we "view[ ] the facts in the light most favorable to
the nonmoving party," we recount the facts here in the light most favor-
able to Walker. See Nat’l City Bank of In. v. Turnbaugh, 463 F.3d 325,
329 (4th Cir. 2006).
                  WALKER v. MEDTRONIC, INC.                  11
ket approval. During discovery, Medtronic produced reports
establishing that the particular SynchroMed pump implanted
in Arnold Walker had been tested prior to implantation and
had been determined to be in compliance with its premarket
approval terms.

   On October 29, 2009, following discovery, Medtronic filed
a renewed motion for summary judgment. It argued that
because discovery had demonstrated that the SynchroMed
pump was designed, manufactured, and sold in accordance
with its premarket approval, Walker’s claims were preempted
by the MDA as interpreted by Riegel. Walker opposed the
motion. She did not dispute that the pump was designed, man-
ufactured, and sold in accordance with its premarket approval.
Rather, she asserted, as she does here, that her claims fell
within the exception for parallel claims articulated in Riegel.
Specifically, she argued that the pump had failed to adhere to
the plus or minus 15 percent specification included in the pre-
market approval materials and, that by failing to administer
medicine within these parameters, it had violated the terms of
its premarket approval.

   The district court granted Medtronic’s renewed motion for
summary judgment. It reasoned that because Walker con-
ceded that the SynchroMed pump was designed, manufac-
tured, and sold in accordance with its premarket approval
terms, her claims did not parallel federal requirements. It also
determined that, because the plus or minus 15 percent flow
accuracy rate referenced in the SynchroMed pump’s premar-
ket approval application was not a formal performance stan-
dard, failure to adhere to the specification was not a violation
of the premarket approval. As such, the district court con-
cluded that all of Walker’s common law tort claims were pre-
empted by the MDA.

                              II.

   On appeal, Walker again asserts that her common law tort
claims are not preempted by the MDA because they fit within
12                WALKER v. MEDTRONIC, INC.
the narrow exception for parallel claims the Supreme Court
carved out in Riegel. We review the district court’s finding of
preemption de novo. Equal Rights Ctr. v. Niles Bolton
Assocs., 602 F.3d 597, 600 (4th Cir. 2010). Here, we first dis-
cuss Riegel and its effect on common law tort claims based
on the failure of FDA-approved medical devices. We then
analyze Walker’s claims in light of Riegel.

                               A.

   In Riegel, the Supreme Court considered whether a plain-
tiff’s common law claims based on the failure of a Class III
medical device were precluded by the MDA’s express pre-
emption clause, which preempts state requirements "different
from, or in addition to" requirements applicable under federal
law. 552 U.S. at 321 (quoting 21 U.S.C. § 360k(a)(1)). To
answer this question, it engaged in a two-part inquiry. 552
U.S. at 321-22. First, the Supreme Court examined "whether
the federal government ha[d] established requirements appli-
cable to" the device in question. Id. at 321. It specifically
found that "[p]remarket approval . . . imposes ‘requirements’
under the MDA." Id. at 322. This is because "the FDA
requires a device that has received premarket approval to be
made with almost no deviations from the specifications in its
approval application, for the reason that the FDA has deter-
mined that the approved form provides a reasonable assurance
of safety and effectiveness." Id. at 323. Therefore, because all
Class III devices are required to undergo the premarket
approval process, federal requirements exist with respect to
all Class III devices.

   Second, the Riegel Court considered whether the plaintiff’s
common law claims imposed any requirements that were "dif-
ferent from, or in addition to" these federal requirements and
"relate[d] to the safety or effectiveness of the device or to any
other matter included in a requirement of the device." Id.
(quoting 21 U.S.C. § 360k(a)). It first recognized that com-
mon law liability necessarily implies that the defendant had a
                   WALKER v. MEDTRONIC, INC.                   13
legal duty and that "a liability award ‘can be, indeed is
designed to be, a potent method of governing conduct and
controlling policy.’" Id. at 324 (quoting Cipollone v. Liggett
Group, Inc., 505 U.S. 504, 521 (1992)). Common law duties,
it went on to hold, therefore ordinarily constitute state require-
ments. Id. It further observed that "[s]tate tort law that
requires [a device] to be safer, but hence less effective, than
the model the FDA has approved disrupts the federal scheme
no less than state regulatory law to the same effect." Id. at
325.

   In sum, the Supreme Court held that the terms of a Class
III device’s premarket approval constitute federal require-
ments and that a common law tort claim premised on different
or additional requirements is preempted by the MDA. Apply-
ing this framework to Riegel’s case, it concluded that her
claims against Medtronic were preempted.

   The Supreme Court did recognize one situation in which a
plaintiff’s common law claims would not be preempted under
the MDA: when "state duties . . . ‘parallel,’ rather than add to,
federal requirements." Id. at 330 (quoting Medtronic, Inc. v.
Lohr, 518 U.S. 470, 495 (1996)). This situation occurs when
claims are "premised on a violation of FDA regulations." Id.
Because Riegel only raised the argument that her claims par-
alleled federal requirements for the first time before the
Supreme Court, it declined to consider the claim.

                               B.

   Here, Walker contends that her common law tort claims
parallel the federal requirements imposed by the SynchroMed
pump’s premarket approval. She argues that the plus or minus
15 percent specification included in Medtronic’s premarket
approval materials became a part of the federal requirements
governing the device. Because the SynchroMed pump alleg-
edly infused an amount of medication outside of these param-
eters, her argument follows, it violated the terms of the
14                WALKER v. MEDTRONIC, INC.
premarket approval. Walker has, however, made concessions
that are fatal to her claim.

   Walker concedes that the SynchroMed pump was designed,
manufactured, and distributed in compliance with the terms of
the FDA’s premarket approval. She concedes that the plus or
minus 15 percent specification is not a formal performance
standard. And she acknowledges, as indeed she must, that
unless her claims parallel federal requirements as opposed to
imposing more stringent ones, they are preempted under the
MDA as interpreted by Riegel.

                               1.

   We first note that this appeal is not about whether the plus
or minus 15 percent flow accuracy specification set forth in
Medtronic’s premarket approval application constitutes a for-
mal performance standard (although, as we explain, it does
not). The issue before us is whether Walker’s claims are pre-
empted by the MDA, as interpreted by the Supreme Court in
Riegel, which provides a rigorous, comprehensive, and exclu-
sive framework that precludes state law tort claims that seek
to impose different or higher standards upon federally
approved devices. Whether the plus or minus 15 percent spec-
ification is a formal performance standard is pertinent because
only such a performance standard could create the type of
binding requirement that would make Walker’s claims impose
requirements parallel to, as opposed to more restrictive than,
those imposed by the FDA. Thus, the status of the plus or
minus 15 percent specification informs our resolution of the
ultimate question posed by this appeal: whether Walker’s
claims are preempted by the MDA.

   Simply because the majority recognizes that the plus or
minus 15 percent specification does not create an ongoing
requirement, however, we do not state, or even suggest, that
the flow accuracy specification is a "mere aspirational figure,"
as the dissent asserts. Post at 20. To the contrary, it informs
                      WALKER v. MEDTRONIC, INC.                          15
the medical community of the results the device is likely to
achieve under optimal circumstances. It also imposes conse-
quences when a SynchroMed pump does not meet the specifi-
cation. Specifically, Medtronic is required to report any such
malfunction to the FDA for consideration in its ongoing eval-
uative process.

   Instead, the majority simply concludes what is incontro-
vertible under FDA regulations: the only mechanism for cre-
ating a binding, ongoing performance requirement is the
creation of a performance standard. And Walker does not dis-
pute that, here, the plus or minus 15 percent specification is
not a performance standard. As such, it cannot bear the weight
the dissent would assign to it. Indeed, if we were to treat the
flow rate as a requirement, we would be imposing a height-
ened standard beyond that of the FDA—which is impermissi-
ble under Riegel. Moreover, as we have noted, such a holding
would upend the carefully calibrated construct Congress cre-
ated in the MDA, balancing the potential rewards of such
devices following the rigorous process of FDA approval
against the cost of preempting common law claims based on
standards different than those imposed by the FDA.

                                    2.

   Riegel held that, because of the congressional balance
reflected in the MDA, a plaintiff’s state law cause of action
based on injuries caused by a Class III medical device could
only survive if the alleged malfunction also violated a federal
requirement. Because the SynchroMed pump’s premarket
approval application makes it clear that ongoing adherence to
the plus or minus 15 percent flow accuracy specification was
not a requirement,4 Walker’s claims based on the device’s
alleged failure to adhere to the specification must fail.
  4
    With respect for the dissent’s suggestion to the contrary, we note that
the opinion of one Medtronic employee, expressed during a deposition,
regarding whether an overinfusion of the SyncrhoMed pump would con-
stitute a violation of the device’s premarket approval has no bearing on the
question of whether the FDA conditioned its premarket approval of the
device upon ongoing adherence to the plus or minus 15 percent flow rate.
16                    WALKER v. MEDTRONIC, INC.
   As discussed above, the FDA may promulgate formal per-
formance standards to which a device must adhere as a condi-
tion of its premarket approval. See 21 U.S.C. § 360d. The
process of creating a formal performance standard requires
adherence to specific procedures. See id. at § 360d(b).
Because the plus or minus 15 percent specification here was
not a formal performance standard, however, Walker cannot
claim that ongoing adherence to it was a requirement of the
SynchroMed pump’s premarket approval.

   That ongoing adherence to the plus or minus 15 percent
specification was not a requirement of the device’s premarket
approval is further demonstrated by the FDA approval letter
and the FDA-approved Technical Manual.5 As noted above,
the approval letter referred to the plus or minus 15 percent
specification as a measure of "delivery accuracy"; it in no way
conditioned the device’s approval on maintaining this metric.
J.A. 93. To the contrary, the letter contained a number of spe-
cific "Conditions of Approval." J.A. 94. These detailed, inter
alia, restrictions on advertising and reporting requirements.
They did not include the plus or minus 15 percent specifica-
tion—or any sort of performance standard.
  5
   We do not necessarily disagree with the dissent’s assertion that "the
FDA’s [premarket] approval and the Conditions of Approval, taken
together, . . . establish[ ] the specific federal requirements for" a Class III
device. Kemp v. Medtronic, Inc., 231 F.3d 216, 228 (6th Cir. 2000). That
a specification is included in a device’s premarket approval application,
however, does not indicate that the specification imposes a binding
requirement for the life of the device—at least not without clear indication
by the FDA through promulgation of a formal performance standard.
Here, it is undisputed that the SynchroMed pump at issue was designed,
manufactured, and sold in compliance with the terms of its premarket
approval—including the plus or minus 15 percent specification. As we
explain, without an express statement in the FDA’s approval materials that
the SynchroMed pump was subject to an ongoing requirement that it never
deviate from the plus or minus 15 percent specification, any attempt to
impose one through civil tort liability would impose additional require-
ments in violation of the MDA as interpreted by Riegel.
                     WALKER v. MEDTRONIC, INC.                         17
   Further, the Technical Manual, also approved by the FDA,
contained a number of warnings making it clear that the plus
or minus 15 percent specification was subject to many vari-
ables. It specifically stated that human error,6 technical error,
or component failure could result in a change in flow accu-
racy. It also clearly listed "overinfusion" and "drug overdose"
as possible consequences of device malfunction. J.A. 109.
Finally, the Technical Manual contained a general warning
about the inherent risks of implanting a device in the "ex-
tremely hostile environment of the human body." J.A. 114.

   In short, nothing in the SynchroMed pump’s premarket
approval application—which was approved in its entirety by
the FDA—purported that the device would always dispense
medication within the range of the plus or minus 15 percent
flow accuracy. Instead, the plus or minus 15 percent specifi-
cation reflects the SynchroMed pump’s output under optimal
conditions, but subject to numerous qualifiers that disclose the
possibility of infusion outside this range. To the extent that
Walker interprets the plus or minus 15 percent specification
as a guarantee of performance, she seeks to impose a more
demanding standard than that of the FDA, rather than a paral-
lel one.

   On this record, we agree with the district court that "[a]n
alleged deviation from manufacturing performance specifica-
tions for a device that has received premarket approval is not
the same thing as noncompliance with the FDA or its regula-
tions." Walker v. Medtronic, Inc., No. 2:07-00317, 2010 WL
4822135, at *5 (S.D. W. Va. Nov. 24, 2010). To the contrary,
because Walker’s argument would require that the Syn-
chroMed pump never deviate from its programmed flow rate
by more than plus or minus 15 percent, and the terms of the
  6
    It should be noted that nothing in our preemption discussion precludes
a state tort claim against a physician who improperly implants the pump
or otherwise negligently causes it to malfunction. Walker has not, how-
ever, made any such allegation here.
18                WALKER v. MEDTRONIC, INC.
device’s premarket approval do not contemplate this result,
she is actually contending that the device should have been
designed differently. Stated another way, given that the Syn-
chroMed pump’s premarket approval specifically included
language detailing the possibility of deviation from the plus
or minus 15 percent specification, it necessarily follows that
any design that eliminated the possibility of such variation
would be "different from, or in addition to" the design
approved by the FDA. See 21 U.S.C. § 360k(a)(1). As the
Riegel court noted, however, "the FDA requires a device that
has received premarket approval to be made with almost no
deviations from the specifications in its approval application,
for the reason that the FDA has determined that the approved
form provides a reasonable assurance of safety and effective-
ness." 552 U.S. at 323. A common law tort claim that presup-
poses a Class III device should have been designed in a
manner other than that contemplated by its premarket
approval is therefore expressly preempted by the MDA as
interpreted by Riegel. Id. at 324-25.

   We note that, in granting premarket approval, the FDA did
precisely what the dissent would have it do: it evaluated,
through a rigorous process, the safety and reliability of the
device at issue. It also recognized, however, that the device’s
safety and reliability cannot be guaranteed indefinitely in the
"extremely hostile environment of the human body," where
myriad other factors external to the device are brought to bear
(although the device at issue here did function in such an
environment, without dispute, for approximately two years).
J.A. 114. It is Walker’s attempt to transform a design specifi-
cation, which the FDA recognizes the device will not always
function in accordance with, into an actionable guarantee, that
seeks to impose an additional requirement as precluded under
Riegel.

  The consensus of the federal courts post-Riegel supports
our conclusion. Specifically, numerous district courts have
held that common law tort claims based on the failure of
                  WALKER v. MEDTRONIC, INC.                  19
devices that were designed, manufactured, and sold in accor-
dance with the terms of their premarket approval were pre-
empted under Riegel. See, e.g., Rankin v. Boston Scientific
Corp., No. 09-177-KSF, 2010 WL 672135, at *4 (E.D. Ky.
Feb. 19, 2010) ("Boston Scientific received premarket
approval for the Maverick Balloon at issue in this case. The
fact that the Maverick Balloon allegedly failed during normal
use does not override the clear language of § 360(a) or the
Supreme Court’s ruling in Riegel that the plaintiffs’ claims
are preempted by federal law."); Banner v. Cyberonics, Inc.,
No. 08-0741, 2010 WL 455286, at *4 (D.N.J. Feb. 4, 2010)
("[I]f the FDA approves a manufacturing process and the
defendant-manufacturer conforms with it, a device thereby
produced that nevertheless does not function as intended does
not give rise to liability."); Williams v. Cyberonics, Inc., 654
F. Supp. 2d 301, 306 (E.D. Pa. 2009), aff’d, 388 F. App’x 169
(3d Cir. 2010) (unpublished) ("To avoid federal preemption,
a plaintiff must make some showing that the medical device
was not manufactured in accordance with FDA standards.");
Clark v. Medtronic, Inc., 572 F. Supp. 2d 1090, 1095 (D.
Minn. 2008) ("Because plaintiff’s claims are not based on a
breach of the MDA as enforced by the FDA, the claims are
not grounded in state laws that ‘parallel’ federal requirements.
Thus, plaintiff’s claims are preempted."). Neither Walker nor
the dissent point to any case law, nor have we found any, in
which a court has reached a contrary conclusion.
   Because the SynchroMed pump was undisputedly
designed, manufactured, and distributed in compliance with
its FDA premarket approval, and Walker’s common law
claims exceed or differ from, rather than parallel, federal
requirements, we hold that each of her specific claims for
negligence, strict liability, and breach of warranty is pre-
empted.
                                III.
   For the foregoing reasons, the judgment of the district court
is

                                                  AFFIRMED.
20                 WALKER v. MEDTRONIC, INC.
WYNN, Circuit Judge, dissenting:

   This case boils down to a choice of whether the Federal
Drug Administration’s ("FDA") specification that a poten-
tially deadly medical device, an internally implanted pump,
"maintain[ ] the delivery accuracy of ±15%" (J.A. 93) is a
requirement, or whether it is a mere aspirational figure.
Because I believe that the accuracy rate specification is
indeed a requirement, and because the medical device’s fail-
ure to meet that requirement underlies Plaintiff Sherry Walk-
er’s state law tort claims, I would hold that her claims are not
preempted under Riegel v. Medtronic, Inc., 552 U.S. 312
(2008). I therefore respectfully dissent.

   In Riegel, the Supreme Court expressly stated that state tort
suits are preempted only to the extent that they impose
requirements "different from, or in addition to" the require-
ments imposed by federal law. 552 U.S. at 321. The Supreme
Court affirmed a Second Circuit opinion that emphasized at
the outset that

     our preemption analysis is quite limited in scope,
     affecting the small universe of cases resting on
     claims alleging liability despite a [premarket]-
     approved device’s adherence to the standards upon
     which it secured FDA premarket approval. We take
     care to explain that we do not hold that all state tort
     claims as to [premarket]-approved devices are pre-
     empted. Thus, tort claims that are based on a manu-
     facturer’s departure from the standards set forth in
     the device’s approved [Pre-Market Approval] appli-
     cation—such as the Riegels’ negligent manufactur-
     ing claim—are not preempted.

Riegel v. Medtronic, Inc., 451 F.3d 104, 106 (2d Cir. 2006)
(emphasis added).

  The Supreme Court established a two-step analysis for
determining if state-law claims are preempted. First, a court
                  WALKER v. MEDTRONIC, INC.                  21
must determine whether "the Federal Government has estab-
lished requirements applicable to" the particular medical
device. Riegel, 552 U.S. at 321. Claims involving a Class III
medical device with Pre-Market Approval automatically clear
step one of the analysis because the Pre-Market Approval pro-
cess establishes specific requirements applicable to the partic-
ular device. Id. at 322-23. In the second step, a court must
determine whether the state law claims are based on require-
ments "different from or in addition to" the federal require-
ments relating to safety and effectiveness. Id. at 323
(quotation marks omitted).

   In my view, Walker’s suit clears both of these hurdles. The
Medtronic SynchroMed EL Infusion Pump ("Pump") at issue
in this case is undisputedly a Class III device with specific
requirements. The first Riegel step is therefore met. Further,
the Pre-Market Approval established a plus or minus 15 per-
cent delivery accuracy requirement for the internally-
implanted Medtronic SynchroMed EL Infusion Pump
("Pump"). Walker’s suit is based on the Pump’s failure to
meet that requirement. Indeed, she proffered evidence, which
we must take as true for summary judgment purposes, that her
husband, Arnold Walker, died because the Pump delivered an
extreme overdose of 258 percent of his prescribed medicine
dosage. Walker’s suit therefore does not impose additional or
different requirements but rather parallels the pre-existing
federal requirements for the Pump. I therefore do not believe
that her suit is preempted under Riegel.

   The majority casts the Federal Drug Administration’s
("FDA") requirement that the Pump "maintain[ ] the delivery
accuracy of ±15%" (J.A. 93) as a mere aspirational figure,
i.e., what "the device is likely to achieve under optimal cir-
cumstances." Ante at 15. I cannot agree. And, apparently, nei-
ther would the FDA. In an amicus brief filed in Horn v.
Thoratec Corp., 376 F.3d 163 (2004), in which the Third Cir-
cuit addressed whether state claims were preempted, the FDA
stated that "the agency’s approval of this [Class III] device
22                WALKER v. MEDTRONIC, INC.
through the PMA process does impose specific requirements
for its design, manufacturing, performance, labeling, and
use." Brief for the United States as Amicus Curiae at 15, Horn
v. Thoratec Corp., 376 F.3d 163 (2004) (No. 02-4597), 2004
WL 1143720, at *15 (emphasis added). Further, "in reviewing
a PMA, FDA considers in great depth and detail the perfor-
mance and design specifications, methods of manufacture,
labeling, and indications for use of a proposed medical
device." Amicus Br. at 16. Nowhere in its 31-page brief did
the FDA even mention the words "performance standard."
Nevertheless, the FDA repeatedly made clear that it can and
does exact performance specifications and requirements in the
ordinary course of the Pre-Market Approval process—which
is precisely what we have in this case.

   The FDA underscored that "although FDA does not itself
design any medical devices, through the PMA approval pro-
cess it certainly establishes ‘specific requirements’ applicable
to a ‘particular device’ because the specifications for that
device’s design, performance, manufacture, labeling, and use
are approved by the agency based on what the applicant sub-
mits. See Kemp v. Medtronic, Inc., 231 F.3d at 216." Id. at 16
(emphasis added). And, notably, "FDA does not, and has
never, used notice-and-comment regulations"—and formal
performance standards are just such regulations, as the major-
ity recognizes—"to approve individual products or to estab-
lish product-specific requirements for manufacture,
performance, labeling, and use. Rather, a PMA order is better
conceptualized as an individual adjudication that imposes
‘specific requirements’ on the device." Id. at 23-24 (emphasis
added).

   Accordingly, the accuracy rate at issue here is a require-
ment for the Pump per the Pre-Market Approval. The accu-
racy rate of "delivery accuracy of ±15%" is included twice in
the PMA approval, which itself was based on information that
Medtronic provided and that included the figure. J.A. 93-94.
Medtronic itself argued in a previous appeal before the Sixth
                      WALKER v. MEDTRONIC, INC.                          23
Circuit that "the FDA’s [Pre-Market] [A]pproval and the Con-
ditions of Approval, taken together, . . . establish[ ] the spe-
cific federal requirements for the" device at issue. Kemp, 231
F.3d 216, 228 (6th Cir. 2000) (quotation marks omitted). The
Sixth Circuit agreed with Medtronic’s position—and so do I.
See id.; see also Horn, 376 F.3d at 171 ("The FDA, when
PMA approval is granted, imposes federal requirements based
on the highly detailed and prescriptive nature of the PMA pro-
cess and the approval order that results from it."). Indeed,
even in this litigation, Medtronic conceded that an overinfu-
sion of medication above 15 percent would violate the
Pump’s Pre-Market Approval. Medtronic’s corporate repre-
sentative for purposes of this case, Patrick L. Johnson, Regu-
latory Affairs Director for the Medtronic Neurological
Business, testified in his deposition as follows:

         Q: Okay. Let me rephrase it then. Assuming
      there are no procedural errors, the physician hasn’t
      done anything wrong and Mr. Walker’s pump has
      been used within the environmental conditions that
      are spelled out in the technical manual and the pump
      because of a system complication, a system error
      overinfuses Mr. Walker by more than 15 percent,
      that would be a violation of the PMA approval for
      this pump, would you agree with that?

        A:    That would be a reasonable statement, yes.

S.J.A.1 248 (objection to form omitted). That is precisely what
Walker is claiming.2
  1
     Certain case materials containing confidential medical information
relating to Arnold Walker were filed under seal. While this deposition
excerpt is found in the sealed joint appendix, it does not pertain to confi-
dential medical information.
   2
     I also note that even Medtronic’s appellate counsel conceded at oral
argument that delivery of more than plus or minus 15 percent of the appro-
priate dosage of medicine would constitute a Pump "malfunction."
24                 WALKER v. MEDTRONIC, INC.
   The majority notes that "neither the FDA’s initial grant of
premarket approval nor its later approvals of supplemental
applications [for the Pump] were subject to any requirement
that [the Pump] comply with a formal performance standard
pursuant to § 360d." Ante at 7. The majority then goes on,
however, to assert, without citation to any support, that "only
such a performance standard could create the type of binding
requirement that would make Walker’s claims impose
requirements parallel to, as opposed to more restrictive than,
those imposed by the FDA." Ante at 14. I cannot agree that
the absence of a formal performance standard for this Class
III device frees the manufacturer from accountability for
ensuring that its device performs as approved, including with
regard to the approved accuracy rate.

   It is instructive to consider what a formal performance stan-
dard is. "Medical devices are developed individually, but
classes of products with similar features can sometimes bene-
fit from a uniform standard of safety and effectiveness. These
are the Class II devices." James T. O’Reilly, 1 Food & Drug
Admin. § 18:18 (3d ed. 2011). Performance standards are a
form of special control that may be instituted when "[t]he
FDA . . . make[s] a finding that a performance standard is
necessary to provide reasonable assurance of the device’s
safety and efficacy." Id. (quotation marks omitted).

   Notably, however, to obtain Pre-Market Approval, a Class
III device manufacturer must always "provide[ ] reasonable
assurance that the product is safe and effective under the con-
ditions of use for which it is labeled . . . ." Id. at § 18:50. This
is echoed in 21 C.F.R. § 860.7, the regulation dedicated to the
"[d]etermination of safety and effectiveness[,]" which equates
the establishment of performance standards for Class II
devices with the Pre-Market Approval of Class III devices.
The regulation states:

     In determining the safety and effectiveness of a
     device for purposes of classification, establishment
                      WALKER v. MEDTRONIC, INC.                          25
      of performance standards for class II devices, and
      premarket approval of class III devices, the Commis-
      sioner and the classification panels will consider the
      following, among other relevant factors:

      (1) The persons for whose use the device is repre-
      sented or intended;

      (2) The conditions of use for the device, including
      conditions of use prescribed, recommended, or sug-
      gested in the labeling or advertising of the device,
      and other intended conditions of use;

      (3) The probable benefit to health from the use of the
      device weighed against any probable injury or illness
      from such use; and

      (4) The reliability of the device.

21 C.F.R. § 860.7(b) (emphasis added).

   Stated differently, as part of every Pre-Market Approval for
a Class III device (in contrast to a Class II device, where these
concerns come into play specifically in establishing formal
performance standards), the FDA must evaluate "safety and
effectiveness" by considering, among other things, "[t]he reli-
ability of the device" and the device’s potential injury versus
potential benefit. Id. Given that even the FDA equates a safety
and effectiveness determination, including consideration of
device reliability, in Pre-Market Approvals for Class III
devices with performance standards for Class II devices,3 I
cannot agree with the majority that "[b]ecause the plus or
minus 15 percent specification here was not a formal perfor-
mance standard, . . . Walker cannot claim that ongoing adher-
  3
    I of course recognize that the FDA "may" (and therefore necessarily
need not) establish a performance standard for Class III devices "as a con-
dition to premarket approval . . . ." 21 C.F.R. § 861.1(b) (emphasis added).
26                WALKER v. MEDTRONIC, INC.
ence to it was a requirement of the [Pump’s] premarket
approval." Ante at 16. Indeed, it seems illogical that the FDA
would place more exacting performance requirements on
Class II devices such as "surgical drapes" (Riegel, 552 U.S.
at 316) than on Class III devices such as "replacement heart
valves, implanted cerebella stimulators, and pace-maker pulse
generators," for which "a less stringent classification would
provide [no] reasonable assurance of safety and effectiveness
. . . ." Id. at 317.

   Nor do I believe that Medtronic’s inclusion of various
warnings in its Pre-Market Approval materials neuters the
"maintaining the delivery accuracy of ±15%" requirement.
Those warnings address, e.g., potential component failure,
conditions under which the device might malfunction (such as
at high altitudes), and human error. Those general warnings
do not change the fact that the specific plus or minus 15 per-
cent accuracy rate requirement is twice stated in the FDA’s
two-page Pre-Market Approval letter, which, per Medtronic,
establishes a device’s requirements. See Kemp, 231 F.3d at
228. Further, Medtronic has not alleged that any number of
the things addressed by the warnings are in play here (e.g.,
Medtronic does not contend that Arnold Walker went hiking
in the Himalayas).

   To be sure, it cannot be said that, under my analysis, device
manufacturers must achieve perfection. Indeed, "the delivery
accuracy of ±15%" itself recognizes that manufacturers may
be given some margin for error. The FDA accepted that mar-
gin, based on Medtronic’s Pre-Market Approval application,
to be plus or minus 15 percent. Perhaps potential liability for
incidents that occur outside of that 30 percent margin for error
is simply a cost of doing business. The ramifications of hold-
ing anything else are indeed serious. If manufacturers are not
held accountable for having their devices perform as approved
by the FDA, they will have little incentive to ensure that
potentially deadly devices function properly. For example, if
Walker’s factual contentions are true (and we must presume
                      WALKER v. MEDTRONIC, INC.                          27
that they are in reviewing summary judgment against her
(Nat’l City Bank of In. v. Turnbaugh, 463 F.3d 325, 329 (4th
Cir. 2006))), the Pump, which was approved with a dosage
accuracy rate of plus or minus 15 percent, instead infused her
husband with 258 percent of the appropriate medication dos-
age, and this extreme overdose killed him. I fail to see
why—in the absence of clear congressional instruction to the
contrary—the Walkers alone should bear the burden of this
malfunction.

   My view is bolstered by the general presumption against
preemption of state law claims. As this Court articulated in a
2008 opinion, "we begin our consideration with the basic
premise that ‘Congress did not intend to displace state law.’
Maryland v. Louisiana, 451 U.S. 725, 746 (1981). . . . The
presumption against preemption has particular force in the
areas of public health and safety that have traditionally been
regulated by the states. See Pinney v. Nokia, Inc., 402 F.3d
430, 457 (4th Cir.), cert. denied, 546 U.S. 998 (2005)." City
of Falls Church v. Fairfax Cnty. Water Auth., 272 F. App’x
252, 256 (4th Cir. 2008) (unpublished). Particularly when
viewed through this lens, I fail to see how Walker’s claims are
preempted.4

   Of course, whether or not Walker can prevail on her claims
remains a very open question. But at stake today is not
whether Walker should win or Medtronic should be held lia-
ble. The question before us is simply whether Walker may
pursue her state law tort claims in light of the FDA’s regula-
  4
   The majority appears to turn the presumption against preemption on its
head when it asserts "That a specification is included in a device’s premar-
ket approval application, however, does not indicate that the specification
imposes a binding requirement for the life of the device—at least not with-
out clear indication by the FDA through promulgation of a formal perfor-
mance standard." Ante at 16 n.5. Under the majority’s analysis, then, in
clear contradiction to precedent, we assume preemption, i.e., additional
requirements via state tort suits, absent clear indication to the contrary.
With this, I cannot agree.
28               WALKER v. MEDTRONIC, INC.
tion of the Pump. I believe that she should be able to do so.
Accordingly, I respectfully dissent.
