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Brian C. v. Valueoptions

United States District Court, D. Utah, Northern Division

October 11, 2017

BRIAN C. and RHONDA C., individually and as guardians of A.C., Plaintiffs,
v.
VALUEOPTIONS, and CONOCOPHILLIPS MEDICAL AND DENTAL ASSISTANCE PLAN, Defendants.

          MEMORANDUM DECISION AND ORDER

          Dale A. Kimball, United States District Judge

         This matter is before the court on Plaintiffs' appeal of Defendants ValueOptions and ConocoPhillips Medical and Dental Assistance Plan's denial of medical benefits under an employee benefits plan governed by the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001 et seq. The parties filed cross motions for summary judgment. On October 3, 2017, the court held a hearing on the motions. At the hearing, Plaintiffs were represented by Brian S. King and Nediha Hadzikadunic, and Defendants were represented by Belinda D. Jones, Henry I. Willett, and Erik A. Christiansen. The court took the matter under advisement. Having fully considered the evidence in the administrative record and law relevant to the motions, the court enters the following Memorandum Decision and Order.

         BACKGROUND

         Plaintiffs appeal Defendants' denial of medical benefits for residential treatment for their teenage daughter, A.C. A.C.'s family had health coverage under the ValueOptions and ConocoPhillips Medical and Dental Assistance Plan (“The Plan”).

         AC was diagnosed with Attention Deficit/Hyperactivity Disorder (“ADHD”) when she was five years old and received Section 504 accommodation under the Rehabilitation Act of 1973. A.C. experienced anxiety and behavioral problems and continued treatment and therapy throughout her elementary and middle school years. In eighth grade, A.C. began having truancy issues at school and her therapists began managing her medication more closely.

         In 2014, at the age of 16, A.C. was seeing a much older boy with whom she smoked marijuana and had sex. In September 2014, Plaintiffs discovered A.C. in their home engaging in such conduct. A.C. ran away from home and was missing for six days. In October 2014, A.C.'s boyfriend brought her home and she informed her parents that she had been living in a drug house. A.C. stated that she would commit suicide and her parents took her to the Memorial Herman emergency room. A.C. was admitted to the West Oaks Psychiatric Hospital for seven days of observation. On October 14, 2014, Plaintiffs placed A.C. in a wilderness program called Second Nature Blueridge in Georgia. A.C. remained at Second Nature until December 24, 2014.

         On December 29, 2014, five days after her release from Second Nature, Plaintiffs admitted A.C. to Solstice Residential Treatment Center in Utah. A.C.'s intake assessment and evaluation diagnosed her as having major depressive disorder, generalized anxiety disorder, oppositional defiant disorder, combined-type ADHD, and parent-child relation problem. However, Solstice did not believe that A.C. exhibited any symptoms in the “severe” category and did not diagnose A.C. with any psychosis, medical physical conditions, or substance abuse problems.

         Shortly after A.C.'s admittance, Plaintiffs submitted a claim for coverage of A.C.'s treatment at Solstice. Defendants reviewed the request for authorization for residential treatment services for “medical necessity.” The Plan provides coverage for “medically necessary” services, which are defined as services that are: (1) appropriate and required for the diagnosis or treatment of the sickness, injury, or pregnancy; and (2) the least expensive and most appropriate diagnostic or treatment alternative.

         The Plan's clinical criteria for admission to residential treatment requires the following six criteria to be met for admission:

1. The child/adolescent demonstrates symptomatology consistent with a DSM-IV-TR (or most current DSM), (Axes I-IV) diagnosis which requires, and can be reasonably be expected to respond to, therapeutic intervention.
2. The child/adolescent is experiencing emotional or behavioral problems in the home, community and/or treatment setting and is not sufficiently stable either emotionally or behaviorally, to be treated outside of a highly structured 24-hour therapeutic environment.
3. The child/adolescent demonstrates a capacity to respond favorably to rehabilitative counseling and training in areas such as problem solving, life skills development, and medication compliance training.
4. The child/adolescent has a history of multiple hospitalizations or other treatment episodes at other levels of care and/or recent inpatient stays with a history of poor treatment adherence or outcomes.
5. Less restrictive or intensive levels of treatment have been tried and were unsuccessful, or are not appropriate to ...

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