United States District Court, D. Utah
LYN M., and DAVID M., as Legal Guardians of L.M., a minor, Plaintiff,
PREMERA BLUE CROSS, and MICROSOFT CORPORATION WELFARE PLAN, Defendant.
MEMORANDUM DECISION AND ORDER
S. Jenkins, United States Senior District Judge.
Motion for Summary Judgment and Defendants' Cross-Motion
for Summary Judgment came before the Court on May 15, 2018,
Brian King and Nediha Hadzikadunic appearing on behalf of
Plaintiffs Lyn M. and David M. as legal guardians of L.M.,
and Gwendolyn Payton appearing on behalf of Defendant
Premera. Plaintiff filed its Motion for Summary Judgment on
April 6, 2018, and Defendants filed their Cross-Motion for
Summary Judgment on that same date. At the May 15, 2018
hearing, the Court heard oral arguments on the motions and
took the matter under advisement.
considered the parties' briefs, the evidence presented,
the oral arguments of counsel, the relevant law, as well as
the full record in this matter, the Court concludes that
Defendants' Motion for Summary Judgment should be GRANTED
and Plaintiffs' Motion for Summary Judgment should be
a dispute over insurance coverage under an ERISA health
insurance plan for L.M's fourteen-month stay at Eva
Carlston Academy, a residential treatment center in Salt Lake
County, Utah, with related costs in excess of $80, 000.
suffered from mental health issues from an early age,
exhibiting symptoms of anxiety and panic attacks early in her
childhood and beginning therapy at eight years old. Around
this time she also began seeing a psychiatrist, was diagnosed
with attention deficit hyperactivity disorder and prescribed
a variety of medications. Her conditions worsened throughout
elementary school and negatively impacted her academic
parents enrolled her in a number of schools in attempts to
find an environment suitable for her mental health
conditions, including a school for "bright children who
had difficulty functioning in a traditional school
environment." The new school environments proved
ineffective, as L.M. struggled to pay attention in class and
maintain an adequate attendance record. L.M.'s condition
continued to deteriorate as the anxiety and depression
intensified, leading her to spend most of her time in her
room and to self-harm by cutting on her upper thighs and
wrists. She attended her freshmen year of high school for
only two-weeks before transferring to the school's
"homebound" program for students who could not
physically attend school. Her participation in this program
ultimately stopped as well, as she stopped interacting with
her family and focused solely on the internet.
session with L.M.'s therapist led to L.M. being placed on
suicide watch in an acute inpatient mental health facility
for four days, because she was planning to kill herself. She
subsequently participated in a two-week outpatient follow-up
program. A few months later, L.M.'s parents decided to
place her in Eva Carlston Academy, a long-term residential
treatment center in Salt Lake County, Utah, where she was
admitted on March 21, 2015. She remained in the treatment
center for roughly fourteen months and showed moderate
improvement over the length of her stay.
parents and legal guardians Lyn and David M. submitted claims
to Premera, the claims administrator of the insurance plan,
for coverage for the treatment costs, which were denied by
letter on March 31, 2015. The stated basis was that the
treatment center did not meet the "intensity of
treatment" requirements under the health plan's
guidelines for inpatient stays, which require in-person
evaluation by a psychiatrist at least once every seven days
and weekly individual therapy. Specifically, Premera provided
the following justification for its denial:
The information that your provider gave to your health plan
shows that the psychiatrist in charge of your treatment
evaluates you in-person once a month, not once every seven
days. The information also shows that you are receiving
individual therapy every other week, not weekly. Therefore,
mental health residential treatment is denied as not
medically necessary after 3/30/15. Your health plan covers
only medically necessary services.
Dkt. No. 20-1, The Administrative Record, p. 66.
April 19, 2016, Lyn and David appealed Premera's denial
of coverage, requesting a review of the adverse benefit
determination for services provided from April 1, 2015 -
forward, as L.M. was still in treatment. On June 3, 2016,
Premera denied Lyn and David's appeal on the basis of
reviews made by a physician board certified in Child and
Adolescent Psychiatry, along with Premera's internal
medical director. They gave the following rationale for their
[L.M] is a 15-year-old female with depression and anxiety.
She was admitted to residential treatment due to problems
with depressed mood and anxiety and a history of suicidal
thoughts. The documentation does not indicate that [L.M.]
continued to experience severe mental health symptoms
requiring 24-hour residential treatment as of April 1, 2015.
This is because there was no documented evidence of ongoing
suicidal and homicidal ideation, self-injury, psychosis, or
severe difficulties in self-care. She could have been treated
in a less restrictive setting, such as a partial
hospitalization program (PHP), instead. As such, continued
residential treatment services would not be considered
standard of care or medically necessary. To be covered, all
mental health treatment must be medically necessary to be
eligible for coverage.
.. .the criterion [of being medically necessary] has not been
met because there is no documented evidence of ongoing
suicidal or homicidal ideation, self-injury, psychosis, or
severe difficulties in self-care.
Dkt. No. 20-1, The Administrative Record, p. 45.
further specified that the treatment was not covered because
of its failure to comply with the following provisions
delineating the required components of "medically
• [The treatment must be] appropriate for the medical
condition as specified in accordance with authoritative
medical or scientific literature and generally accepted
standards of medical practice.
• [The treatment must be] essential to the diagnosis or
the treatment of an illness, accidental injury, or condition
that is harmful or threatening to the enrollee's life or
health, unless it is provided for preventative services when
specified as covered under this plan.
• [The treatment must be] cost-effective, as determined
by being the least expensive of the alternative supplies or
level of service that are medically effective and that can be
safely provided to the enrollee. A health intervention is
cost-effective if no Other available health intervention
offers a clinically appropriate benefit of a lower cost.
• [The treatment must not be] primarily for the comfort
or convenience of the enrollee, the enrollee's family,