• Filing. Published in U.S. District Court Northern District of California on August 6, 2020 (Case no. 14-cv-02346-JCS; related case no. 14-cv-05337 JCS).
  • Backgroun As a follow-up to the 2019 Wit decision regarding UBH’s flawed use of its internal Level of Care Guidelines (LOCGs), the Court had deferred on the question of whether the diagnosis-specific Coverage Determination Guidelines (CDGs) incorporate elements of the LOCGs, which in turn would have made the use of CDGs inappropriate (for not meeting generally accepted standards of care — GASC).
  • Holding. Judge Joseph C. Spero ruled that the 216 CDGs being challenged by the Plaintiffs all did incorporate one or more elements of the LOCGs, which in turn made their use for making benefit determinations wrongful for the same reasons the use of LOCGs was wrongful.
  • Analysis. Judge Spero in an impressive fashion systematically evaluated and connected all of the 216 CDGs to the LOCGs by identifying eight categories of linkage points.