• Filing. Published in U.S. District Court of the District of Montana, Helena Division on November 5, 2020 (Case no. 18-05-H-CCL).
  • Background. The Plaintiff Jessica had a complicated history of medical conditions including gastric disorders, anorexia nervosa, and generalized anxiety disorder.  Care was denied by the Defendant Plan (BCBS) based on findings that her treatment did not meet MCG guidelines for admission to an RTC, but her condition did qualify for less intensive outpatient (IOP).   Throughout the appeals process, the denial was upheld because the RTC level of treatment did not meet the “medical necessity” terms under the policy.  As part of the requirements for medically necessary care the plan noted that care must be provided under the GASC principles when it wrote:  “‘generally accepted standards of medical practice’ means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations and the view of Physicians practicing in relevant clinical areas and any other relevant factors.” Since the health plan was not given discretion to interpret the policy, the Court used a “de novo” standard to review in this case.
  • Holding. In considering cross motions for summary judgement, Judge Charles C. Lovell ruled that the plan must reimburse the Plaintiff for her care at the RTC during the summer of 2015.  He notes that “MCG should not have been applied in this case and that once disregarded, and the entire administrative record is reviewed, Jessica has demonstrated by a preponderance of the evidence that her (RTC) was medically necessary.”    The judge reviewed Jessica’s case history in detail and ruled that the plan had missed the boat in fully considering her various health conditions and medical history – along with the family dynamics.  The judge also ruled that the RTC reimbursement would be based on an ‘in-network” exception than a single case agreement (SCA).  He also awarded the Plaintiff’s attorney fees but asked the parties to meet to discuss the amount.
  • Analysis.  The Court relied on the Wit decision in part when making its ruling.  In stressing the sub-acute focus of RTC treatment, the Plaintiff asserted “the MCG improperly focus on acute symptoms and presenting problems, rather than the effective treatment of the patient’s overall condition and that treatment aimed only at managing crises is not effective.”

In terms of this coverage determination, the Defendant asserted that “the MCG are an industry standard clinical decision support tool that cite 32 different scientific articles and medical literature relied upon when Milliman created the guidelines.”

In citing Charles W v Regence, the Judge Lovell notes that MCG might be a helpful tool but is not intended to operate as the sole basis for denying care.   The criteria should not be used as “the sole measure of medical necessity.”  He explains:

With this rationale in mind, a review of the administrative record reveals it was precisely due to the acute and imminent factors outlined in the MCG, and relied upon by BCBS in examining the medical necessity of Jessica’s treatment, that many relevant factors detailed in Jessica’s treatment, progress, and struggles were not considered by BCBS. Conversely, there were factors applied in Jessica’s request for benefits that had absolutely no relation to her unique mental health issues.