United Behavioral Health v. J.D.S. ex rel. C.N.M.
| Decision Date | 17 June 2020 |
| Docket Number | No. 517,517 |
| Parties | UNITED BEHAVIORAL HEALTH v. J.D.S. o.b.o C.N.M. |
| Court | Court of Special Appeals of Maryland |
Circuit Court for Montgomery County
Case No. 447732V
UNREPORTED
Fader, C.J., Shaw Geter, Greene, Clayton, Jr. (Senior Judge, Specially Assigned), JJ.
Opinion by Fader, C.J.
* This is an unreported opinion, and it may not be cited in any paper, brief, motion, or other document filed in this Court or any other Maryland Court as either precedent within the rule of stare decisis or as persuasive authority. Md. Rule 1-104.
The appellant, United Behavioral Health ("United"), asks this Court to reverse an order of the Circuit Court for Montgomery County that itself reversed a decision of the Maryland Insurance Administration ("MIA"). Although MIA determined that United had not violated Maryland insurance law in denying a claim for reimbursement of substance abuse treatment incurred by the appellee, C.M., the circuit court ordered United to provide full reimbursement for the cost of the treatment. United presents us with a single question: "Was the MIA's determination that [United] did not violate Maryland's insurance laws supported by substantial evidence?" We hold that it was, and will therefore reverse the circuit court's order and uphold MIA's determination.
This appeal arises from a complaint C.M. filed with MIA seeking review of United's decision to deny his claim for reimbursement of the cost of inpatient substance abuse treatment. The statutory authority for C.M.'s complaint is § 15-10A-04(c)(1) of the Insurance Article, pursuant to which "it is a violation of [Maryland law] for a carrier1 to fail to fulfill the carrier's obligations to provide or reimburse for health care services specified in the carrier's policies or contracts with members."
Section 15-10A-04(c)(1) is enforced by MIA, "an independent unit of the State government" that is headed by the Maryland Insurance Commissioner. Id. § 2-101. Upon receiving an "adverse decision" from an insurance company,2 and after exhausting the insurer's internal grievance process, an insured "may file a Complaint with the Commissioner" seeking review of that decision. Id. § 15-10A-03(a)(1). In such a review, the health insurance carrier has the burden of persuading the Commissioner that the carrier's decision to deny coverage was correct. Id. § 15-10A-03(e)(1). For complaints that challenge a determination of medical necessity, as C.M.'s complaint did, the Commissioner is required to "seek advice from an independent review organization or medical expert." Id. § 15-10A-03(d). A person aggrieved by the Commissioner's initial decision can demand a contested case hearing, as C.M. did here. Id. § 2-210(a)(2). The Commissioner's final decision following such a hearing is then subject to judicial review by a circuit court. Id. § 2-215(d). Any party may appeal from the circuit court's judgment to this Court. Id. § 2-215(j)(1).
C.M. was a member of a UnitedHealthcare Choice Plus health insurance policy offered through his employer (the "Policy"). According to the Policy, United Healthcare (a related entity to the appellant, United) bears the responsibility to, among other things, "Determine Benefits" and "Pay for Our Portion of the Cost of Covered Health Services." The Policy provides coverage only for "Covered Health Services," which, among other criteria, are limited to services that are "Medically Necessary."3 The Policy defines "Medically Necessary" as:
The Policy contains 35 different numbered categories of "Covered Health Services," which are covered if, among other criteria, they are Medically Necessary, received during the policy period, and provided to a person covered by the Policy. Category 20 is "Mental Health Services and Substance Use Disorder Services . . . received on an inpatient basis in a Hospital, Related Institution, Residential Treatment Facility, or entity licensed by the Department of Health and Mental Hygiene to provide Residential Crisis Services." The Policy provides benefits under such coverage for services "provided on an inpatient basis" including, among others, "[d]iagnostic evaluations and assessment," "[t]reatment planning," "[r]eferral services," "[m]edication evaluation and management," and "[t]reatment and counseling."
Category 21 is "Mental Health Services and Substance Use Disorder Services . . . received on outpatient basis in a provider's office or an Alternate Facility." The Policy provides benefits under such coverage for many, but not all,5 of the same types of services listed under Category 20, but only for services which are "provided on an outpatient basis." Category 21 also provides coverage for "Intensive Outpatient Treatment," which the Policy defines as "a structured outpatient mental health or substance-related and addictive disorders treatment program that may be free-standing or Hospital-based and provides services for at least three hours per day, two or more days per week."
Under the Policy, "[s]ome Covered Health Services require prior authorization." For any services that are to be provided by an out-of-network provider, the Policy states that the insured is "responsible for obtaining prior authorization before [he or she] receive[s] the services." Prior authorization is required for all "Mental Health and Substance Use Disorder Services," including both inpatient and outpatient treatment programs, that are to be provided by an out-of-network provider.
In a section titled "How to File a Claim," the Policy states that an insured who receives services from an out-of-network provider is "responsible for requesting payment from us" by "fil[ing] the claim in a format that contains" specified information. One such requirement is "[a]n itemized bill from your provider that includes the Current Procedural Terminology (CPT) codes6 or a description of each charge."
C.M. developed an opioid addiction after taking medications that had been prescribed for him after undergoing surgery. On February 12, 2016, he sought treatment for the addiction at the Richard J. Caron Foundation residential treatment facility ("Caron"), an out-of-network provider. C.M. entered the Grand View Program at Caron, which is advertised as an "[a]ddiction rehab and behavioral health treatment [program] for executives needing discretion." According to program materials, the Grand View Program "differs from [Caron's] traditional adult treatment programs in several ways that offer greater latitude and amenities as well as . . . [a] more similar patient community." The Grand View Program features include:
Although a representative from Caron had contacted United on February 11 to inquire "what the benefits were for certain levels of care," neither C.M. nor Caron sought prior authorization for C.M.'s treatment. On February 13, Caron requested authorization from United for five days of residential substance abuse services for C.M. A clinical assessor at United denied authorization at that time, offered an "ambulatory detox" level of care instead,7 and referred C.M.'s case to peer review to assess the medical necessity of the requested residential services.
United's Associate Medical Director, Dr. Theodore Allchin, conducted the peer review. In a letter dated February 16, Dr. Allchin stated that "it is my determination that no authorization can be provided from 02/12/2016 forward" because C.M.'s case did not reach the residential rehabilitation level of care under the applicable Level of Care Guidelines.8 Based on the status of C.M.'s condition, Dr. Allchin stated that "care could continue in the Substance Use Disorder Intensive Outpatient Program."
C.M. continued to receive residential treatment at Caron until March 5. During his stay, C.M. received a number of "passes" to leave the Caron facility, including twice to have dinner with his family and twice to attend religious functions. At the conclusion of C.M.'s stay, Caron issued an invoice for $36,520.00. The invoice, which identifies United as the payer, includes a single line item entry for each day of C.M.'s 22-day stay, with the description "RESIDENTIAL TREATMENT - CHEM DEP," and an associated charge of $1,660.00. The invoice did not identify charges for any individual services provided to C.M., although at some point Caron or C.M. provided...
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