Murray v. Ibm, No. 2:07-cv-115.

• Decision Date: 27 March 2008
• Docket Number: No. 2:07-cv-115.
• Parties: Laura MURRAY, Plaintiff, v. INTERNATIONAL BUSINESS MACHINES CORPORATIONS, Defendant.
• Court: U.S. District Court — District of Vermont

557 F.Supp.2d 444

Laura MURRAY, Plaintiff, v. INTERNATIONAL BUSINESS MACHINES CORPORATIONS, Defendant.

No. 2:07-cv-115.

United States District Court, D. Vermont.

March 27, 2008.

COPYRIGHT MATERIAL OMITTED

Karen S. Allen, Lisman, Webster & Leckerling, P.C., Burlington, VT, for Plaintiff.

Robert D. Rachlin, Downs Rachlin Martin PLLC, James W. Spink, Spink & Miller, PLC, Burlington, VT, for Defendant.

OPINION AND ORDER

WILLIAM K. SESSIONS III, Chief Judge.

Plaintiff Laura Murray challenges Defendant International Business Machines Corporation's ("IBM") final decision to deny insurance benefit coverage for bilateral reduction mammoplasties and thighplasties. Plaintiffs action arises under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C.A § 1001 et seq. Before the Court are Plaintiffs Motion for Summary Judgment and Defendant's Cross-Motion for Summary Judgment. For the reasons set forth below, Plaintiffs motion is DENIED and Defendant's motion is GRANTED.

I. BACKGROUND

The following facts are undisputed. Murray is an IBM employee. As an IBM employee, Murray receives health care benefits through IBM's self-insured plan, the IBM Medical and Dental Plan ("the Plan"). (AR 93.) During the time period relevant to this action, MVP Select Care, Inc. ("MVP") administered the Plan in Vermont. (AR 78.)

In April 2003, Murray underwent gastric bypass surgery, which was covered by the Plan. (AR 63.) She lost over 200 pounds and as a result of the substantial weight loss, she was left with significant amounts of excess skin on her arms, abdomen, breasts, and thighs. (AR 34.) Plaintiff developed intertrigo (rashes or irritation caused by chafing of the skin) on the areas where the excess skin rubbed against itself. (AR 33.) On April 7, 2005, Murray underwent surgeries to remove the excess skin on her arms and abdomen. (AR 31.) MVP initially denied coverage for these surgeries but overturned the denial because of "functional impairment and recurrent intertrigo." (AR 72.)

After these surgeries, Murray's plastic surgeon requested approval for bilateral reduction mammoplasties and bilateral thighplasties. (AR 63.) An MVP medical director reviewed the claim, and on October 6, 2005, MVP sent Murray a letter denying coverage because there was no "evidence of conservative treatments or exercise regimen failure." (AR 16.) On December 12, 2005, Murray appealed the denial. She argued that the procedures were medically necessary and included supporting letters from three physicians. (AR 26, 27, 28.) None of these letters mentioned conservative treatments. Dr. William Bremer, an MVP Medical Director, reviewed Murray's claim and found that there was a lack of "documentation of a failed, adequately supervised trial of conservative measures" and that neither the thighplasties nor mammoplasties were medically necessary. (AR 18.)

The Plan defines "medically necessary" as follows:

Except where state law or regulation requires a different definition, "Medically Necessary" or "Medical Necessity" shall mean those health care services rendered in accordance with generally accepted standards of practice in the medical or dental professions that are:

• Required to diagnose or treat an illness, injury, disease or its symptoms

• Considered effective for the patient's medical condition, illness, injury or disease

• Clinically appropriate, in terms of type, frequency, site and duration

• Not primarily for the convenience of the patient, patient's family or Healthcare Provider, a Physician or an other Healthcare provider

• Rendered in the least intensive setting that is appropriate for the safe delivery of the services and supplies

• Rendered in the most efficient and economical way; not more costly than an alternative service or sequence or services which would produce equivalent therapeutic or diagnostic results beneficial to the diagnosis or treatment of the covered person's illness, injury or disease

• Based on credible scientifically based guidelines of national medical, research or governmental agencies

(Def.'s Facts Ex. 1 at 47.)

On January 3, 2006, MVP sent Murray a letter stating that it was upholding its initial denial based on Dr. Bremer's findings. (AR 18.)

On December 29, 2006, Murray initiated the final appeal to the IBM Plan Administrator, Rosemarie Barnes. (AR 53.) In her appeal, Murray included physicians' letters and medical records indicating that she had tried conservative treatments. (AR 103, 105, 111, 112, 114, 127.) Of the medical records submitted, the dermatologist's report, dated February 22, 2005, contained a prescription for topical creams. (AR 103.) The remaining letters and medical records contained statements that conservative treatments provided only temporary relief. (AR 105, 111, 112, 114, 127.)

Barnes sent the record to IPRO, an independent medical review firm. (AR 61.) At IPRO, a physician, board certified in plastic surgery, reviewed the claim. The IPRO physician determined that the procedures were not medically necessary under the guidelines set forth by the American Society of Plastic Surgeons ("ASPS"). (AR 62.) The guidelines set forth by the ASPS in its position paper, "Treatment of Skin Redundancy Following Massive Weight Loss," state: "Resection of redundant skin and fat folds is medically indicated if panniculitis ... or uncontrollable intertrigo ... is present." (AR 2.) Upon review of Murray's records, the IPRO physician found that the records did not document "the failure of medically supervised conservative therapy to control [Murray's] intertrigo." (AR 65.) The IPRO physician concluded that in Murray's case "[b]ody contouring is not a medically necessary procedure in the absence of documentation that confirms the failure of medically supervised conservative treatment.... Body contouring is desirable for aesthetic reasons, but it is not medically necessary." Id. Based on the two previous reviews by MVP medical directors and the IPRO physician's review, Barnes denied Murray's appeal. Murray was notified by letter dated March 1, 2007 that her appeal had been denied. (AR 20.)

II. Standards of Law

A. Legal Standard for Summary Judgment

Under Fed.R.Civ.P. 56(c), summary judgment is appropriate if the offered evidence shows no genuine issue of material fact and the moving party is entitled to judgment as a matter of law. The burden is on the moving party to demonstrate the absence of a genuine issue of material fact, and in considering the motion, the Court must resolve all ambiguities and draw all inferences in favor of the nonmoving party. Ocean Ships, Inc. v. Stiles, 315 F.3d 111, 117 (2d Cir.2002) (citing Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 255, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986)). Where both parties have moved for summary judgment, "the court must evaluate each party's motion on its own merits, taking care in each instance to draw all reasonable inferences against the party whose motion is under consideration." Schwabenbauer v. Bd. of Educ. of City School Dist. of City of Olean, 667 F.2d 305, 314 (2d Cir.1981).

B. Legal Standard for Review of Denial of Benefits under ERISA

The parties agree that the "arbitrary and capricious" standard of review applies to the Court's review of IBM's decision to deny Murray's claim for benefits under the Plan. The Plan grants the Administrator "exclusive authority and discretion to interpret the terms of the benefits described [therein]." (Def.'s Facts ¶ 3, Ex. 1 at 2.) "[W]here the written plan documents confer upon the plan administrator the discretionary authority to determine eligibility, we will not disturb the administrator's ultimate conclusion unless it is `arbitrary and capricious.'" Pagan v. NYNEX Pension Plan, 52 F.3d 438, 441 (2d Cir.1995). The arbitrary and capricious standard of review is highly deferential to the plan administrator's determination, and the Court "may overturn a decision to deny benefits only if it was `without reason, unsupported by substantial evidence or erroneous as a matter of law.'" Id. at 442 (quoting Abnathya v. Hoffmann-La Roche, Inc., 2 F.3d 40, 45 (3d Cir.1993)).

Furthermore, the Court generally will not look to evidence outside the Administrative Record upon review of a plan administrator's decision. "[A] district court's review under the arbitrary and capricious standard is limited to the administrative record." Miller v. United Welfare Fund, 72 F.3d 1066, 1071 (2d Cir.1995); accord Zervos v. Verizon New York, Inc., 277 F.3d 635, 647 (2d Cir.2002) ("[W]e limit our review of [the plan administrator's] decision to the administrative record.").

III. Discussion

The Court finds Murray's argument that IBM's decision was arbitrary and capricious unsupported by the facts in the file. Murray argues that IBM's decision was arbitrary and capricious for three primary reasons. First, she argues that IBM's decision was unreasonable because it was inconsistent with its previous decision to provide coverage for the first set of surgeries. Murray claims that IBM applied a higher standard to the second approval request, even though, as she claims, the "merits for the second surgeries [were] the same for the primary surgery." (Pl.'s Reply Mem. in Supp. of Mot. for Summ. J. 14.) IBM asserts that evaluating the medical necessity of each set of surgeries separately was reasonable and proper in light of the accepted medical standards. (Def.'s Mem. of Law in Supp. of Cross Mot. for Summ. J. & Opp'n To Pl.'s Mot. for Summ. J. 6, 16.)

The file reveals substantial evidence to support IBM's determination that the second set of surgeries did not amount to an inconsistent application of the Plan. Under the criteria set forth by the ASPS, surgery to remove excess skin is medically necessary if there are "specific signs and symptoms that 1) are clearly related to the excess skin[;] 2) are health threatening or cause significant functional disability[;] and 3) have failed to improve despite...