J.L. v. Anthem Blue Cross

• Decision Date: 30 December 2020
• Docket Number: Case No. 2:18-cv-00671-DBB-DBP
• Citation: 510 F.Supp.3d 1078
• Parties: J.L., C.L., and A.L., Plaintiffs, v. ANTHEM BLUE CROSS and Northrop Grumman Health Plan, Defendants.
• Court: U.S. District Court — District of Utah

510 F.Supp.3d 1078

J.L., C.L., and A.L., Plaintiffs,

v.ANTHEM BLUE CROSS and Northrop Grumman Health Plan, Defendants.

Case No. 2:18-cv-00671-DBB-DBP

United States District Court, D. Utah.

Signed December 30, 2020

Brian S. King, Brian S. King PC, Nediha Hadzikadunic, Gross & Rooney, Salt Lake City, UT, for Plaintiffs.

Angela Shewan, Jessica P. Wilde, Timothy C. Houpt, Mark D. Tolman, Jones Waldo Holbrook & McDonough, Salt Lake City, UT, for Defendant Anthem Blue Cross.

Jeffery Scott Williams, Nelson Christensen Hollingworth & Williams, Salt Lake City, UT, John Mylan Traylor, Pro Hac Vice, Richard E. Nowak, Pro Hac Vice, Samuel P. Myler, Pro Hac Vice, Mayer Brown LLP, Chicago, IL, for Defendants. Northrup Grumman Health Plan.

MEMORANDUM DECISION AND ORDER GRANTING [61] DEFENDANTS’ MOTION FOR SUMMARY JUDGMENT AND DENYING PLAINTIFFS’ [62] MOTION FOR SUMMARY JUDGMENT

David Barlow, United States District Judge

Defendant Anthem Blue Cross (Anthem) denied Plaintiffs’ claims for healthcare reimbursement under an employee welfare benefits plan. Plaintiffs contend their claims were wrongly denied under the Employee Retirement Income Security Act of 1974 (ERISA).¹ Before the court are the parties’ cross-motions for summary judgment.² Having considered the briefing and the relevant law, the court concludes the motions may be resolved without oral argument.³ The court grants Defendants’ Motion for Summary Judgment and denies Plaintiffs’ Motion for Summary Judgment.

BACKGROUND

A.L. and her parents receive health insurance coverage through the Northrup Grumman Health Plan (Plan), for which Anthem is the third-party claims administrator.⁴ The parties agree that the Plan confers on Anthem the discretionary authority to construe and interpret the Plan.⁵

A.L. was admitted to Sunrise Residential Treatment Center, a licensed residential treatment center, on May 13, 2016.⁶ She received residential mental health treatment at Sunrise until August 7, 2017.⁷ Anthem initially determined that A.L.’s treatment at Sunrise from May 13, 2016 until May 23, 2016 was medically necessary and authorized coverage for those days.⁸

The Plan defines residential treatment as "[t]wenty-four (24) hours per day specialized treatment involving at least one physician visit per week in a facility-based setting."⁹ The Plan provides that residential treatment would include certain group therapies, family therapy, individualized treatment, and that beneficiaries "will be prepared to receive the majority of their treatment in a community setting."¹⁰

Services "are considered medically necessary if the claims administrator determines that a medical practitioner, exercising prudent clinical judgment, would provide it to a covered individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms and that are ... [i]n accordance with generally accepted standards of medical practice."¹¹ Generally accepted standards of medical practice are "standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, national physician specialty society recommendations and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors."¹²

For residential treatment to qualify as medically necessary under the Plan, the treatment must meet certain criteria:

Severity of Illness Criteria

Residential treatment center is considered medically necessary when the member has all of the following:

A. The member is manifesting symptoms and behaviors which represent a deterioration from the member's usual status and include either self injurious or risk taking behaviors that risk serious harm and cannot be managed outside of a 24 hour structured setting or other appropriate outpatient setting; and

B. The social environment is characterized by temporary stressors or limitations that would undermine treatment that could potentially be improved with treatment while the member is in the residential facility; and

C. There should be a reasonable expectation that the illness, condition or level of functioning will be stabilized and improved and that a short term, subacute residential treatment service will have a likely benefit on the behaviors/symptoms that required this level of care, and that the member will be able to return to outpatient treatment; and

D. Member's clinical condition is of such severity that an evaluation by physician or other provider with prescriptive authority is indicated at admission and weekly thereafter.¹³

The Plan then identifies certain "continued stay criteria":

Continued Stay Criteria

Residential treatment center is considered medically necessary when the member continues to meet Severity of Illness criteria and has A, and one of B, C, or D:

A. Member evaluation by a physician or other provider with prescriptive authority occurs weekly; and

B. Progress with the psychiatric symptoms and behaviors is documented and the member is cooperative with treatment and meeting treatment plan goals; or

C. If progress is not occurring, then the treatment plan is being re-evaluated and amended with goals that are still achievable; or

D. There is no access to partial hospital care if this is needed.¹⁴

The Plan provides that "[f]or continued authorization of the requested service, Continued Stay criteria must be met along with Severity of Illness criteria."¹⁵ Although A.L.’s residential treatment was covered as medically necessary from May 13, 2016 until May 23, 2016, on August 1, 2016, Anthem informed Plaintiffs that it denied coverage for A.L.’s treatment after May 23, 2016 on the basis that residential treatment was not medically necessary.¹⁶ Anthem provided the rationale from the medical reviewer:

You went to residential treatment for your mental health condition and your stay was approved. A request was made to extend your stay. The plan's clinical criteria considers short-term residential treatment medically necessary for those who meet certain criteria and improvement can be expected from a short-term residential stay. The information we received after your stay was approved shows the program you're in is planned for 6 to 8 months. A program of this length is not considered short term residential treatment. For this reason the request for you to remain in this long-term residential treatment program is denied as not medically necessary. There may be other options to help you work through the issues you're dealing with, such as short-term residential treatment or outpatient services. We encourage you to discuss other treatment options with your doctor. It may help your doctor to know we reviewed this request using the plan clinical guideline called Psychiatric Disorder Treatment - Residential Treatment Center (RTC) CG-BEH-03.¹⁷

On January 13, 2017, Sunrise, on Plaintiffs’ behalf, submitted a Level One appeal of the denial.¹⁸ On February 23, 2017, Anthem denied the Level One appeal, explaining that "[a]fter the treatment you had, you were no longer at risk for serious harm that needed 24 hour care. You could have been treated with outpatient services. We based this decision on this health plan guideline (Psychiatric Disorder Treatment – Residential Treatment Center (RTC) (CG-BEH-03))."¹⁹

On August 17, 2017, Plaintiffs, on their own behalf, filed a Level Two appeal.²⁰ They provided additional information about A.L.’s prior treatment including a letter from one of A.L.’s mental health providers, who treated her from November 2005 to June 2009,²¹ and a letter from another of A.L.’s mental health provider, who treated her from November 2015 to May 2016.²²

On September 14, 2017, Anthem responded to Plaintiffs’ Level Two appeal.²³ Anthem partially overturned its previous denial, and informed Plaintiffs that it would cover the additional days of A.L.’s residential treatment from May 23, 2016 through July 1, 2016.²⁴ Anthem then denied coverage for the remainder of A.L.’s time at Sunrise, providing,

We still do not think this is medically necessary for you. We believe our first decision is correct for the following reason. After the treatment you had, you were no longer at risk for serious harm that needed 24 hour care. You could have been treated with outpatient services as of July 2, 2016. We based this decision on this health plan guideline (Psychiatric Disorder Treatment – Residential Treatment Center (RTC) (CG-BEH-03)). This review included the appeal request letter from your parents, 1040 pages of medical records submitted for the second level appeal review, 509 pages of records from your first level appeal review and 20 pages of medical records submitted during the initial review.²⁵

Plaintiffs sued Anthem to recover benefits under ERISA and for violation of the Mental Health Parity and Addiction Equality Act.²⁶ The court previously granted Defendants’ Partial Motion for Summary Judgment, dismissing Plaintiffs’ second cause of action.²⁷ The remaining issue before the court now is Plaintiffs’ first cause of action to recover benefits under ERISA.

LEGAL STANDARD

A. Summary Judgment Standard

"The court shall grant summary judgment 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."²⁸ "When both parties move for summary judgment in an ERISA case, thereby stipulating that a trial is unnecessary, ‘summary judgment is merely a vehicle for deciding the case; the factual determination of eligibility of benefits is decided solely on the administrative record, and the non-moving party is not entitled to the usual inferences in its favor.’ "²⁹

B. Review of Benefits Decision under ERISA

First, the court must determine the standard under which to review Anthem's decisions. The United States Supreme Court has observed that "the validity of a claim to benefits under an ERISA plan is likely to turn on the interpretation of terms in the plan at...