United States District Court, D. Utah
MEMORANDUM DECISION AND ORDER
S. Jenkins United States Senior District Judge
matter came before the court for hearing on March 23, 2017.
Brian S. King appeared on behalf of Plaintiffs John B., Linda
B., and Matthew B. (collectively "B. Family").
James L. Barnett and Jack M. Englert appeared on behalf of
Defendants Connecticut General Life Insurance Company and
Cigna Behavioral Health, Inc. (collectively
"Cigna") and Defendant Intel Corporation Medical
Benefit Plan ("Plan").
considered the parties' briefs, the evidence presented,
the arguments of counsel, and the relevant law, the court
finds that Cigna's decision to deny coverage of Matthew
B.'s residential treatment at Island View Residential
Treatment Center ("Island View") after March 6,
2013 was not arbitrary and capricious.
such, Defendants' combined summary judgment motion is
Plan is a self-funded employee benefit plan sponsored by
Intel Corporation. Cigna is the Plan's claims
administrator. During the time period relevant to this case,
Matthew B. was a covered dependent under the Plan.
order for medical services to be covered under the Plan, such
services must meet Cigna's guidelines for medical
necessity. In the Cigna Standards and
Guidelines/Medical Necessity Criteria for Treatment
of Behavioral Health and Substance Use Disorders
("Cigna Standards and
Guidelines'"), the following "basic
elements of medical necessity" are identified for
residential mental health treatment for children and
care services that a Provider, exercising prudent clinical
judgment, would provide to a patient for the purpose of
evaluating, diagnosing or treating an illness, injury,
disease or its symptoms, and that are:
a) Required to meet the essential health needs of the
b) Consistent with the diagnosis of the condition for which
they are required;
c) Consistent in type, frequency and duration of treatment
with scientifically-based guidelines as determined by medical
d) Required for purposes other than the convenience of the
provider or the comfort of the patient;
e) Rendered in the least intensive setting that is
appropriate for the delivery of health care.
addition, the Cigna Standards and Guidelines
identify criteria that children and adolescents, once
admitted to a residential treatment facility, must meet for
individual continues to meet all basic elements ...