• Filing. Published in U.S. District Court for the District of Utah on December 30, 2020 (Case no. 2:18-cv-00671-DBB-DBP).
  • Background. Defendant Plan/TPA denied care to dependent for RTC services. The plan denied long-term residential treatment program as not being medically necessary.  The plan defines residential treatment as 24 hours per day of specialized treatment involving at least one physician visit per week in a facility-based setting.  The plan provides for continued authorization using both “severity of illness” and “continued stay” review criteria.  The denial was upheld during the appeals process even through Plaintiffs provided additional medical information.  Both parties filed cross motions for summary judgement.
  • Holding. Using the arbitrary and capricious standard, Judge David Barlow granted Defendant’s motion for summary judgement.
  • Analysis.  In the court opinion, the Judge Barlow noted:

The federal regulations require Anthem to provide Plaintiffs with:

(i) The specific reason or reasons for the adverse determination;

(ii) Reference to the specific plan provision on which the determination is based;

(iii) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary;

. . .

(v)(B) If the adverse determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the claimant’s medical circumstances, or a statement that such explanation will be provided free of charge upon request.

He noted that the plan substantially complied with ERISA’s procedural requirements, including the fact that both appeal letters issued by the plan provided an explanation of the clinical judgement behind the lack of medical necessity determination.  Judge Barlow added that Plaintiff’s argument that the plan failed to consider all of the medical records from the treating providers was without merit.  He also added that Plaintiff’s contention that the two sets of criteria referenced above should be mutually exclusive are without merit.