Ariana M. v. Humana Health Plan of Tex., Inc.

• Decision Date: 19 February 2016
• Docket Number: CIVIL ACTION NO. H-14-3206
• Citation: 163 F.Supp.3d 432
• Parties: Ariana M., Plaintiff, v. Humana Health Plan of Texas, Inc., Defendant.
• Court: U.S. District Court — Southern District of Texas

163 F.Supp.3d 432

Ariana M., Plaintiff,

v.Humana Health Plan of Texas, Inc., Defendant.

CIVIL ACTION NO. H-14-3206

United States District Court, S.D. Texas, Houston Division.

Signed February 19, 2016

James C. Plummer, Amar Bharat Raval, Plummer Kuykendall, Houston, TX, Lisa S. Kantor, Kanto Kanto, LLP, Elizabeth K. Green, Kantor & Kantor LLP, Northridge, CA, for Plaintiff.

Carlos R. Soltero, Ellen Burkholder Cochran, Rachael K. Padgett, McGinnis Lochridge et al., Austin, TX, for Defendant.

MEMORANDUM AND OPINION

Lee H. Rosenthal

, United States District Judge

This is an ERISA case challenging the denial of benefits under a group health plan insured and administered by Humana Health Plan of Texas, Inc. (“Humana”). Ariana M., a dependent eligible for benefits under the plan, sued Humana under 29 U.S.C. § 1132(a)(1)(B)

after it terminated payments for her partial hospitalization treatment. Humana moved for summary judgment on the grounds that: Ariana M.'s adverse determination for preauthorization of treatment and claims for benefits was reasonable and based on substantial evidence; even under a de novo review, Ariana M.'s condition did not satisfy the medical-necessity criteria required to continue partial hospitalization treatment; and Ariana M.'s claims were fully and fairly reviewed by board-certified psychiatrists and Humana complied with ERISA procedural requirements. (Docket Entry No. 39). Ariana M. responded and sought summary judgment in her favor on the grounds that: the denial was improper even under an abuse-of-discretion standard of review; Ariana M.'s treatment met the medical-necessity criteria; and the record failed to support Humana's decision to deny benefits. (Docket Entry No. 44).

Based on the pleadings, the parties' arguments and submissions, the administrative record, and the applicable law, this court grants Humana's motion for summary judgment and denies Ariana M.'s motion. Final judgment is entered by separate order. The reasons are explained below.

I. Background

Ariana M. is a 19-year-old female who suffers from an eating disorder and depression. From April 15, 2013 to June 4, 2013, Humana authorized and paid for partial hospitalization treatment at Avalon Hills Treatment Center in Logan, Utah. Humana denied benefits on June 5, 2013, after finding that the treatment was no longer medically necessary.

The plan defines “medically necessary” to mean:

health care services that a health care practitioner exercising prudent clinical judgment would provide to his or her patient for the purpose of preventing, evaluating, diagnosing or treating an illness or bodily injury , or its symptoms. Such health care service must be:

• In accordance with nationally recognized standards of medical practice;

• Clinically appropriate in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness or bodily injury ;

• Not primarily for the convenience of the patient, physician or other health care provider; and

• Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the patient's sickness or bodily injury .

For the purpose of medically necessary , generally accepted standards of medical practice means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations, the view of physicians practicing in relevant clinical areas and any other relevant factors.

(Administrative Record at 877). The plan uses a set of clinical standards—the “Mihalik criteria”—to assess medical necessity. In Ariana M.'s case, eight of these criteria must be present “throughout the episode of care” to make the services medically necessary:

PM.A.g.1. The services must be consistent with nationally accepted standards of medical practice.

PM.A.g.2. The services must be individualized, specific, and consistent with the individual's signs, symptoms, history, and diagnosis.

PM.A.g.3. The services must be reasonably expected to help restore or maintain the individual's health, improve or prevent deterioration of the individual's behavioral disorder

or condition, or delay progression in a clinically meaningful way of a behavioral health disorder or condition characterized by a progressively deteriorating course when that disorder or condition is the focus of treatment for this episode of care.

PM.A.g.4. The individual complies with the essential elements of treatment.

PM.A.g.5. The services are not primarily for the convenience of the individual, provider, or another party.

PM.A.g.6. Services are not being sought as a way to potentially avoid legal proceedings, incarceration, or other legal consequences.

PM.A.g.7. The services are not predominantly domiciliary or custodial.

PM.A.g.8. No exclusionary criteria of the health plan or benefit package are met.

(Id. at 1566).

The following set of criteria must be satisfied to initiate treatment:

PM.A.i.1. Based on a behavioral health history and mental status evaluation completed by a psychiatrist or by a behavioral health professional licensed, certified, or registered to practice independently and reviewed by a psychiatrist prior to initiation of treatment, the individual is diagnosed as having, or there is strong presumptive evidence that the individual has a diagnosis of, a mental disorder or condition according to the most recent version of the Diagnostic and Statistical Manual of Mental Disorders that requires, and is likely to respond to, professional therapeutic intervention.

PM.A.i.2. A concurrent medical assessment does not indicate that a non-behavioral medical condition is primarily responsible for the symptoms or behaviors necessitating treatment in this setting.

PM.A.i.3. The individual does not have adequate internal resources or an adequate external support system to maintain functioning without the support of an intensive multi-modal, multi-disciplinary treatment program that includes medical and/or nursing care.

PM.A.i.4. With treatment at this level, the individual is capable of controlling behaviors and/or seeking professional help when not in a structured treatment setting.

PM.A.i.5. If the services being proposed have been attempted previously without significant therapeutic benefit, there is a clinically credible rationale for why those same services could be effective now.

PM.A.i.6. The place of service meets the Service Setting Criteria for Partial Hospital Treatment: Mental Health as described on page 29.

One of the following Treatment Initiation Criteria is also required.

PM.A.i.7. As a result of the mental disorder or condition, the individual is now a clear and present danger to self, a clear and present danger to others, or unable to provide for basic self-care needs resulting in impending, serious self-harm.

PM.A.i.8. As a result of the mental disorder or condition:

PM.A.i.8.1. The individual demonstrates significant impairment in social, occupational, scholastic or role functioning that represents a deterioration in level of functioning.

AND

PM.A.i.8.2. The individual has participated in and failed a substantial course of traditional or intensive outpatient treatment in the past three months.

OR

PM.A.i.8.3. It is clinically probable that the individual will require initiation of a higher level of care if services are not provided at this level.

(Id. at 1566–67).

These criteria must be satisfied to continue treatment:

PM.A.c.1. The individual continues to meet the treatment initiation criteria each day that services are provided at this level.

PM.A.c.2. There is an individualized plan of active, professionally directed treatment that specifies the goals, interventions, time frames, and anticipated outcomes appropriate to:

PM.A.c.2.1. Improve or prevent deterioration or delay progression in a clinically meaningful way of the symptoms of, or impairment in functioning resulting from, the mental disorder or condition that necessitated initiation of treatment.

AND

PM.A.c.2.2. Address a co-morbid substance use disorder or condition, if one exists.

(Id. ).

Humana denied benefits for continued partial hospitalization treatment, after a medical review by Dr. Manjeshwar Prabhu, a board-certified psychiatrist and contract physician with Humana's behavioral-health vendor, LifeSynch. Dr. Prabhu examined Ariana M.'s medical files and consulted with her therapist at Avalon Hills in a peer-to-peer review. (Id. at 324–28). Avalon Hills told Dr. Prabhu that Ariana M. was not “progressing in treatment; she appears to be at her baseline behaviors.” (Id. at 326). She was not “[suicidal], [homicidal], or psychotic,” and she had “no complications with her eating disorder.” (Id. ). Dr. Prabhu concluded that Ariana M. did not qualify for continued treatment under the Mihalik criteria. Dr. Prabhu cited criterion PM.A.c.1, which requires that the patient meet the “treatment initiation criteria” each day to continue receiving benefits. Dr. Prabhu found that Ariana M. was not “in imminent danger to [herself] or others,” as required by criterion PM.A.i.7. Her clinical records did not show “medical instability” or “functional impairments,” as required by PM.A.i.8.1. And Ariana M. could be safely treated at a lower level of care, such as an intensive outpatient program. Criterion PM.A.i.8.3 requires a “clinical[ ] probab[ility] that the individual will require initiation of a higher level of care if services are not provided at this level.” Dr. Prabhu reported that continuing the treatment after June 4, 2013, was not medically necessary. Humana denied coverage for continued treatment and provided Ariana M. and Avalon Hills with a notice and explanation of the denial the same day. (Id. at 329–48).

Avalon Hills appealed. Ariana M.'s claim was reviewed by Dr. Neil Hartman, a board-certified psychiatrist with a third-party review company, Advanced...