Filing. Published in U.S. District Court for the District of Utah on August 17, 2020 (Case no. 2:19-cv-00590-DBB-JCB).
Background. Plaintiff’s child was admitted to a RTC in Utah that provides MH/SUD subacute inpatient treatment to adolescents. Defendants covered the first 2 out of 11 months of treatment. Defendant used Optum’s Level of Care Guidelines (LOCGs) to deny reimbursement. The denial was upheld during the appeals process in part because the reviewers concluded that the child was making progress and the child no longer met the guidelines for RTC treatment, and recommended outpatient care. Plaintiffs filed a Parity Act claim (aka the second cause of action) asserting that the Defendant’s “medical necessity criteria for intermediate level mental health treatment benefits are more stringent or restrictive than the medical necessity criteria applied to intermediate level medical or surgical benefits”.
Holding. Judge Dave Barlow granted Defendants’ motion to dismiss the Parity Act claim and Plaintiff’s second cause of action is also dismissed without prejudice. But Judge Barlow granted Plaintiffs leave to amend the Complaint to correct the deficiency.
Analysis. Defendants assert that Plaintiffs have not plausibly alleged disparate treatment of MH/SUD when compared to med/surgical care in this case. In this case, Plaintiffs have alleged sufficient facts regarding their own experience, but do not offer well-pleaded facts regarding the comparator medical classification. The Complaint contains only conclusory statements about the alleged as-applied discrimination involving the med/surgical analogue. But the Court also notes too that the health plan never produced copies of the plan documents or medical necessity criteria to afford Plaintiffs to be more specific.