United States District Court, D. Utah, Northern Division
BRIAN C. and RHONDA C., individually and as guardians of A.C., Plaintiffs,
VALUEOPTIONS, and CONOCOPHILLIPS MEDICAL AND DENTAL ASSISTANCE PLAN, Defendants.
MEMORANDUM DECISION AND ORDER
A. Kimball, United States District Judge
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.
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
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.
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,
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.
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
Plan's clinical criteria for admission to residential
treatment requires the following six criteria to be met for
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