Howard W. v. Providence Health Plan
| Decision Date | 23 January 2023 |
| Docket Number | 2:21-CV-01346-JHC |
| Parties | HOWARD W, WENDY W, and KATHRYN H.-W., Plaintiffs, v. PROVIDENCE HEALTH PLAN, and the SWEDISH HEALTH SERVICES EMPLOYEE BENEFITS PLAN, 519, Defendants. |
| Court | U.S. District Court — Western District of Washington |
Plaintiffs Howard W., Wendy H., and Kathryn H.-W., bring suit against Defendants Providence Health Plan (PHP) and Swedish Health Services Employee Benefits Plan, 519 (Plan) under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001 et seq. Plaintiffs bring two causes of action: (1) to recover benefits under 29 U.S.C. § 1132(a)(1)(B); and (2) for a violation of the Mental Health Parity and Addiction Equity Act of 2008 (Parity Act), which is enforceable under ERISA, 29 U.S.C. § 1132(a)(3). Before the Court are the parties' cross-motions for summary judgment. Dkts. ## 44 51. The Court has considered the materials filed in support of, and in opposition to, the motions, and the balance of the case file.
The Court also heard oral argument on the cross-motions. Being fully advised, and for the reasons below, the Court GRANTS Defendants' motion and DENIES Plaintiffs' motion.
Plaintiffs Howard W. and Wendy H. seek reimbursement for their daughter H.-W.'s stays at Pacific Quest, an outdoor “wilderness program” in Hawaii, and Maple Lake Academy (Maple Lake) in Utah. AR001655[1]; Dkt. # 2 at 2. H.-W., through her father, was a member covered by the Plan a self-funded employee welfare benefits plan sponsored by Swedish Health Services (Swedish). Dkt. # 2 at 2; AR000226. PHP, the Plan's claims administrator, handled members' claims for medical benefits under the Plan AR000226-27.
The Plan covers only “medically necessary” treatment defined as:
A medical service or supply that meets all the following criteria:
It is required for the treatment or diagnosis of a covered medical condition. It is the most appropriate supply or level of service that is essential for the diagnosis or treatment of the patient's covered medical condition....
AR000122. “The fact that a service or supply is furnished, prescribed or recommended by a physician or other provider does not, of itself, make it medically necessary.” Id. The Plan excludes from coverage “wilderness programs that focus primarily on education, socialization or delinquency” and “therapeutic schools.” AR000071-73.
Also with prior authorization, the Plan covers non-emergency residential mental health services that are medically necessary. AR000041; AR000062; AR000084-85. If prior authorization is not obtained but the service is verified as medically necessary, the Plan covers the service, but the patient incurs a $300 penalty. AR000041. Under the Plan, residential treatment programs provide “a 24-hour level of care seven days a week for patients with longterm or severe mental health or chemical dependency conditions,” where “[c]are is medically monitored, with 24-hour medical and nursing availability.” AR000122. Residential treatment programs require “at least weekly physician visits.” AR000277.
The Plan covers non-emergency residential mental health services when authorized by PHP's authorizing agent, Optum, “under standards generally applied by Optum.” AR000062; AR000100. Optum relies on its “Level of Care Guidelines” for mental health conditions (Guidelines), which it describes as a “set of objective and evidence-based behavioral health criteria used by medical necessity plans to standardize coverage determinations.” AR000278. The Guidelines' common admission criteria for all levels of care require that:
AR000279; AR000293.
The Guidelines define a residential treatment center as: “A sub-acute facility-based program which delivers 24-hour/7-day assessment and diagnostic services, and active behavioral health treatment to members who do not require the intensity of nursing care, medical monitoring and physician availability offered in Inpatient.” AR000286; AR000300. The Guidelines' residential treatment center admission criteria require first that the member satisfy the common admission criteria. AR000287; AR000301. The Guidelines' second and third criteria require that:
The AR reflects H.-W.'s history of behavioral problems, mental health diagnoses, and treatment efforts. In 2011, when she was around 10 years old, H.-W. was diagnosed with bipolar disorder, generalized anxiety disorder, and oppositional defiance disorder. AR001463; AR001558; AR001600. She was prescribed medications to stabilize her mood, including Lithium, Tegretol, Seroquel, and Focalin. AR001464; AR001558; AR001734. In February 2013, H.-W. called the police, believing her mother was poisoning her with her medications. AR001464. H.-W. was transported to the hospital, but she returned home because there were no available beds in the inpatient psychiatric unit. Id. Later that year, H.-W. shared for the first time suicidal ideas with her mother, such as “jumping off a roof.” AR001464; AR001559. In July 2013, after becoming increasingly argumentative and “having destructive tantrums” in her house, she was admitted to the inpatient psychiatric unit at Seattle Children's Hospital for eight days. AR001464.
Between the summer of 2013 and summer of 2016, H.-W.'s condition improved, before worsening again in the fall of 2016. See AR001465. In December 2016, H.-W. began cutting herself superficially with scissors. AR001465; AR001560; AR001642; AR007773-75. Around this period, she prepared a “suicide kit,” containing a mixture of Adderall, Tylenol, and alcohol. AR001465; AR007776-78.
On April 20, 2017, H.-W. was admitted to the University of Utah Neuropsychiatric Institute (UNI), an inpatient psychiatric hospital. AR001602. She remained at UNI for three months. AR001442. During her stay, H.-W. “did not engage in any self harm, aggression or treatment refusal.” AR001442-43. While there, H.-W. was diagnosed with Autism Spectrum Disorder. AR001442. Upon her discharge, the UNI treatment team “strongly recommend[ed] a long-term residential treatment placement,” advising that if she “returns home, resumes outpatient treatment, and attends a regular public high school, she [would be] at high risk of becoming a danger to herself and reverting to a state of emotional, social, and academic dysfunction.” AR001602. UNI recommended residential treatment for H.-W. to “receive medication management, family therapy, and individual therapy.” AR001655. But when H.-W. was discharged, she was less argumentative and had no self-harm or suicidal ideations. AR001423; AR001657. Her doctors stated, “At the time of discharge, [H.-W.] did not represent an acute or imminent danger to herself or others and, as such, was appropriate for discharge ....” AR001657. According to the discharge summary, H.-W. was being sent “to Pacific Quest wilderness program until an opening [became] available at Maple Lake.” AR001655.
Pacific Quest's promotional brochure states that during a typical stay, students may take academic courses and engage in “practical life skills,” such as “meal planning, cooking, and selfcare.” AR001756. During her stay, H.-W. engaged in yoga, strength training, hiking, and swimming. AR001441. H.-W. participated in “different projects in camp,” including maintaining a gecko habitat, “making items with duct tape,” and “rebuilding rock walls.” AR001443. H.-W. attended classes, such as Hawaiian Culture and Environmental Literacy, for which she received an academic transcript. AR008240.
Around early 2018, Plaintiffs submitted to PHP a claim for reimbursement. Pacific Quest had billed Plaintiffs for residential treatment. AR 8218-22. In March 2018, Plaintiffs sent to PHP the medical records from H.-W.'s stay at Pacific Quest, per PHP's request. AR001421; AR008217. The Pacific Quest records did not include individual therapy notes, group therapy notes, or physician notes, see AR001421-46, AR008217-48, despite Pacific Quest's brochure stating that participants receive two individual therapy sessions per week, AR001753. Pacific Quest's discharge summary describes H.-W.'s “therapeutic process” for each week of her stay, chronicling more of her activities. AR001443-45. For example, it says that H.-W “harvested fruit in camp” and “led a landwork project to chop down a banana tree and expressed feeling ‘proud' of herself.” AR001444. On another occasion, H.-W. “was given a large role in camp regarding meal preparation,” and she said that “cooking was helpful for her self-regulation.” Id. The discharge summary lists H.-W.'s main concerns as “anxiety, apparent manipulative use of self-harm talk and gestures, continued emotional instability, fragile self-concept, . . ....
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