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Amy G. v. United Healthcare

United States District Court, D. Utah

May 21, 2018

AMY G. and GARY G., individually and as guardians of A.G., a minor, Plaintiffs,
v.
UNITED HEALTHCARE, UNITED BEHAVIORAL HEALTH, and the GEICO CORPORATION CONSOLIDATED WELFARE BENEFIT PLAN, Defendants.

          MEMORANDUM OPINION AND ORDER

          BRUCE S. JENKINS UNITED STATES SENIOR DISTRICT JUDGE

         INTRODUCTION

         Plaintiffs Amy G. and Gary G. (collectively "Plaintiffs") and Defendants United Healthcare, United Behavioral Health, and the GEICO Corporation Consolidated Welfare Benefit Plan (collectively "Defendants") filed and fully briefed cross motions for summary judgment.[1]The motions came before the court for hearing on May 2, 2018. Brian King appeared on behalf of Plaintiffs. Timothy Branson appeared on behalf of Defendants. On May 7, 2018, the court requested supplemental briefing from the parties, [2] which the parties provided.[3]

         Having considered the parties' briefs, the evidence presented, the arguments of counsel, and the relevant law, the court find that Defendants' denial decision regarding residential treatment center benefits was reasonable under an arbitrary and capricious standard of review, and the court hereby GRANTS Defendants' motion for summary judgment.[4]

         BACKGROUND

         The following briefly outlines the pertinent undisputed facts in this action, drawn from the parties' summary judgment briefing:

         • GEICO Corporation is the Plan Sponsor of The Medical, Dental and Vision Care Plan (the "Plan"), a self-funded welfare plan under the GEICO Consolidated Plan.

         • The Claims Administrator for the Plan is United HealthCare Services, Inc. and its affiliates, including United Behavioral Health ("collectively United"), which makes coverage determinations for mental health and substance abuse.

         • A.G, the minor son of Amy G. and Gary G., is a beneficiary of the Medical Plan.

         • Discovery Ranch is a residential treatment center. Before A.G.'s admission to Discovery Ranch on April 9, 2015, where he would stay for the next 16 months, his father on March 5, 2015, and then his mother on April 7, 2015, called United seeking benefit information, which was provided. United advised Amy G. that Discovery Ranch was an out-of-network facility, and that she must obtain prior authorization for the admission.

         • Discovery Ranch requested prior authorization from United on April 10, 2015.

o Craig from Discovery Ranch, a Master's level provider, spoke with Monica Vanek from United, a licensed professional counselor. Ms. Vanek recorded a variety of information regarding A.G., including the absence of current and past suicidal/homicidal ideation or attempts, self-injurious behavior, violence toward others, substance abuse, psychosis, or any report of problems with eating, sleeping and self-care. She also recorded that he was alert, oriented to his situation, depressed, with a little mania, high energy, constantly talking, no delusions or hallucinations, with impulsivity, hopelessness and ADD. She advised that she could not authorize the admission to Discovery Ranch, but would refer the matter to a United physician reviewer.

         • On April 11, 2015, Dr. Thomas A. Blocher, M.D., United Associate Medical Director, reviewed the matter, and Discovery Ranch was advised that day that the request for prior authorization was denied.

         • On April 13, 2015, Dr. Blocher communicated such denial to A.G.'s parents by letter, stating, in part, as follows:

Your son admitted for treatment of depression associated with family conflict. After talking with your doctor, it is reported that your child has made progress and no longer needs the type of care and services provided in this setting. He was not a danger to himself or others. He was cooperative with the medications and cooperating with the doctors. His behavior was under good control. He did not require 24 hour nursing care. There have been no aggressive, aberrant, or self-harming behaviors.
Based on the Optum Level of Care Guideline for the Mental Health Residential Treatment Center Level of Care, it is my determination that no authorization can be provided from 04/09/2015 and forward.
Our decision was based on clinical guidelines. The guidelines used for the decision are based on the following:
- American Association of Community Psychiatrists. (2010). Level of Care Utilization System for Psychiatric and Addiction Services, Adult Version.
- American Academy of Child and Adolescent Psychiatry. (2001). Child and Adolescent Service Intensity Instrument, Child and Adolescent Care and Utilization System, Version l.5.[5]

         • On September 29, 2015, A.G.'s parents appealed United's denial, arguing that the denial rationale indicated that United had not properly utilized the relevant guidelines. Specifically, A.G.'s parents contended that the denial rationale that A.G. was not "a danger to himself or others, " was contrary to the admission criterion, which requires that the patient not be a threat to self or others.

         • By letter dated October 9, 2015, United, specifically, Rakesh J. Desai, M.D., Associate Medical Director, resolved the appeal from A.G.'s parents and upheld the denial of authorization for coverage for A.G.'s admission to Discovery Ranch. The appeal denial letter states, in part, as follows:

After fully investigating the substance of the appeal/grievance, including all aspects of clinical care involved in this treatment episode, I have determined that benefit coverage is not available for the following reason(s):
Based on the UBH Level of Care Guideline for the Mental Health Residential Treatment Center Level of Care, it is my determination that no authorization can be provided from 4/09/2015 forward.
Your child was admitted for treatment of depression, mood instability and family conflict. After reviewing the case notes, it is noted that your child's condition did not meet Guidelines for coverage of treatment in this setting. Your child was no [sic] at risk of harm to self or others. Your child was not aggressive and had not been engaging in any self-injurious behaviors immediately prior to admission. Your child could have continued care in the Mental Health Outpatient setting with medication monitoring, individual and family therapy.[6]

         • By letter dated April 1, 2016, A.G.'s parents requested an "independent external review of [A.G.'s] residential treatment claims from Discovery Ranch by an ...


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