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

• Decision Date: 14 September 2018
• Docket Number: CIVIL ACTION NO. H-14-3206
• Parties: ARIANA M., Plaintiff, v. HUMANA HEALTH PLAN OF TEXAS, INC., Defendant.
• Court: U.S. District Court — Southern District of Texas

ARIANA M., Plaintiff, v. HUMANA HEALTH PLAN OF TEXAS, INC., Defendant.

CIVIL ACTION NO. H-14-3206

UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF TEXAS HOUSTON DIVISION

September 14, 2018

MEMORANDUM AND OPINION

Ariana M. sued Humana Health Plan of Texas, Inc., under the Employee Retirement Income Security Act ("ERISA"), alleging that Humana had wrongfully denied benefits for 106 days of partial hospitalization to treat an eating disorder. See 29 U.S.C. § 1132(a)(1)(B). Humana had paid for 49 days of partial hospitalization before determining that Ariana M. did not meet the criteria for continued coverage at that level. Instead, she was covered for the next level of care, intensive outpatient. This court granted summary judgment for Humana, holding that it did not abuse its discretion in denying the benefits. Ariana M. appealed. On appeal, the Fifth Circuit acknowledged that its standard of review for ERISA cases was at odds with that of most circuits and changed the law. Ariana M. v. Humana Health Plan of Tex., Inc., 884 F.3d 246 (5th Cir. 2018) (en banc). The Fifth Circuit held that district courts are to review de novo a plan administrator's decision to deny coverage under an ERISA plan. Id. at 256. The Fifth Circuit vacated the order granting summary judgment and remanded for this court to apply the de novo standard.

On remand, both Ariana M. and Humana moved for summary judgment. Ariana M. argued that her continued partial hospitalization was medically necessary; Humana argued that the administrative record showed that it was not necessary and moved to strike the materials that Ariana M. attached to her motion because they were outside the administrative record. The court heard oral argument on the motions.

Based on the pleadings, the parties' arguments and submissions, the administrative record, and the applicable law, the court grants Humana's motion to strike and motion for summary judgment and denies Ariana M.'s cross-motion for summary judgment. A de novo review of the administrative record reveals that Ariana M.'s continued partial hospitalization was not medically necessary after June 4, 2013, after she had been covered for 49 days. Final judgment is entered by separate order. The reasons are set out in detail below.

I. Background

A. Facts

1. The Plan Terms

Ariana M. is a minor. In 2013, she lived with her parents and three younger siblings in Woodlands, Texas. Ariana M.'s father participated in the group health plan sponsored by Eyesys Vision Plan Inc. and administered by Humana. Throughout 2013, Ariana M. was a dependent eligible for benefits under the plan.

Ariana M. has a history of an eating disorder characterized by compulsive exercising, purging, and restricting based on a belief that she was overweight. She also has a history of cutting herself. She has received extensive treatment. Since 2007, Ariana M. had received outpatient treatment, including intensive outpatient treatment, from her primary care provider. (Admin. Recordat 131-32). In 2008, 2011, and 2012, Ariana M. was admitted to treatment centers for partial hospitalization.¹

Ariana M.'s plan authorized a maximum of 90 days of "partial hospitalization care, treatment in a psychiatric day treatment facility, crisis stabilization unit, or residential treatment center for children or adolescents." (Id. at 794 (emphasis omitted)). Her plan defined "outpatient" to mean that "you are not confined as a registered bed patient." (Id. at 880). "Inpatient" meant that "you are confined as a registered bed patient." (Id. at 876). The plan defined an "intensive outpatient program" to include:

• Group therapeutic sessions greater than one hour a day, three days a week;

• Behavioral health therapeutic focus;

• Group sessions centered on cognitive behavior constructs, social/occupational/educational skills development and family interaction;

• Additional emphasis on recovery strategies, monitoring of participation in 12-step programs and random drug screenings for the treatment of chemical dependency; and

• Physician availability for medical and medication management.

(Id.). "Partial hospitalization" is defined as:

services provided by a hospital, health care treatment facility, chemical dependency treatment center, crisis stabilization unit, psychiatric day treatment facility or residential treatment center for children and adolescents in which patients do not reside for a full 24-hour period:

• For a comprehensive and intensive interdisciplinary psychiatric treatment for minimum of 5 hours a day, 5 days per week;

• That provides for social, psychological and rehabilitative training programs with a focus on reintegration back into the community and admits children and adolescents who must have a treatment program designed to meet the special needs of that age range; and

• That has physicians and appropriately licensed behavioral health practitioners readily available for the emergent and urgent needs of the patients.

(Id. at 880-81 (emphasis omitted)). "Residential treatment" for children and adolescents meant treatment in an institution that:

• Provides residential care and treatment for emotionally disturbed individuals; and

• Is accredited as a residential treatment center by the Council on Accreditation of Healthcare Organizations or the American Association of Psychiatric Services for Children.

(Id. at 883). The plan covered partial hospitalization for medically necessary treatment, defining "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 a sickness 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 sickness 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.

(Id. at 877). Humana used a set of clinical criteria—contained in the Mihalik Group Medical Necessity Manual for Behavioral Health: Partial Hospitalization Treatment Mental Health Care—to assess the medical necessity of partial hospitalization in treating mental illness. In Ariana M.'s case, eight criteria had to be present "throughout the episode of care" to make the services medically necessary. The first criterion incorporated national standards of medical care; the remaining criteria provided details.

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 . . . .

One of the following Treatment Initiation Criteria

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