• Filing. Complaint filed in U.S. District Court for the Eastern District of New York, April 29, 2020 (Case no. 2:19-cv-01969).
  • This class action case arises from Anthem and MCG’s development, adoption, and use of certain clinical coverage criteria for determining whether residential treatment of mental health conditions is “medically necessary,” as that term is defined in the written terms of the employer-sponsored welfare benefit plans that Defendants administer. Named plaintiff’s son suffers from major depression, multiple anxiety disorders and cannabis use disorder and was denied residential treatment based on the decision that the care was not medically necessary.  Plaintiff exhausted their administrative appeal remedies before filing the legal action.

The complaint asserts that the plan defines medical necessity to mean, at least in part, that services are consistent with generally accepted standards of care (GASC) or medical practice. Yet, Anthem’s medical necessity criteria for residential mental health treatment are far more restrictive than those generally accepted standards. As such, Defendants’ development, adoption, and use of these criteria violate the written terms of those plans and Anthem’s fiduciary duties.

Complaint asserts that Anthem breached its fiduciary duty under ERISA and also violated the Parity Act.  Plaintiff is seeking monetary, injunctive and equitable relief.

  • Complaint Insights. The complaint provides insights into the MH/SUD GASC requirements and how Anthem did not meet those thresholds.  Among other details, the Plaintiffs allege: “In the area of mental health and substance use disorder treatment, there is a continuum of intensity at which services are delivered. There are generally accepted standards of medical practice for matching patients with the level of care that is most appropriate and effective for treating patients’ conditions.” The pleading reference many examples of GASC including:  AACP; LOCUS; CALOCUS; AACAP and CASII – among others.

The complaint details several key factors to take into account when promoting MH/SUD GASC highlighting the following when matching patients with the appropriate level of care:

  1. Understand that MH/SUD disorders are long-term and chronic;
  2. Implement comprehensive, coordinated approach to care to accommodate co-occurring disorders;
  3. When matching patients to the right level of care, a less restrictive environment is appropriate only if it is likely to be safe and just as effective;
  4. When there is ambiguity regarding the appropriate level of care, err on the side of caution by placing the patient in a higher level of care;
  5. Effective treatment also includes treatment aimed at preventing relapse or deterioration of the patient’s condition and maintaining the patient’s level of functioning;
  6. The appropriate duration of MH/SUD treatment is based on the individual needs of the patient and there is no specific limit on the duration of such treatment;
  7. The unique needs of children and adolescents must be taken into account when making level of care decisions in part because they are not fully developed in the psychiatric sense; and
  8. Treatment should be made based upon a holistic, biopsychosocial assessment that involves consideration of multiple dimensions.

The class action outlines how Anthem’s internal UM criteria, and MCG’s UM criteria, which it later used, was far more restrictive than GASC.  Where third party references were cited in the UM criteria, those references often were not properly interpreted in a manner that reduced coverage.  Anthem also was criticized for using a sub-substandard static decision tree as part of the UM approval process.

Here is an illustrative example highlighting the problems with MCG guidelines:

“Even if patients meet the unjustifiably stringent acuity thresholds (as described in the complaint), the MCG RTC Guidelines provide that residential treatment is not medically necessary if treatment at a lower level of care is “feasible.” As described above, however, under generally accepted standards of medical practice, treatment at a less intensive level of care must be “as effective” as the more intensive level of care—not merely “feasible.”