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Jo H. v. Cigna Behavioral Health

United States District Court, D. Utah, Central Division

August 27, 2018

SANDY JO H., individually and as guardian of COLBY W. and M.W., minors, Plaintiff,
v.
CIGNA BEHAVIORAL HEALTH, and THE INTERVENTION INC. MEDICAL BENEFIT PLAN, Defendants.

          ORDER AND MEMORANDUM DECISION

          TENA CAMPBELL U.S. DISTRICT COURT JUDGE

         Plaintiff Sandy Jo H. (Sandy) enrolled her son M.W. and daughter Colby W. in Diamond Ranch Academy, a residential care facility in southern Utah, because of their behavioral problems. Her insurance plan, the Intervention Inc. Medical Benefit Plan, and its claim administrator, Cigna Behavioral Health (Cigna), determined that residential treatment was not medically necessary for either child and refused to cover the costs of treatment. Sandy appealed to an independent review organization, which agreed with Cigna's determinations. Sandy now appeals to the court. Reviewing for abuse of discretion, the court finds that Cigna's determinations were reasonable and denies Sandy's Motion for Summary Judgment.

         BACKGROUND

         The Intervention, Inc. Medical Benefit Plan

         Sandy's employer, Intervention, Inc., established its Medical Benefit Plan (the Plan) for eligible employees and their dependents. Sandy is a participant in the Plan, and M.W. and Colby are covered dependents. The Plan grants Cigna, its claims administrator, “discretionary authority to determine whether a claim should be paid or denied on appeal and according to the Plan provisions.” (Admin. R. at Plan 6.)[1]

         The Plan only covers services that are medically necessary, and gives the following medical necessity criteria for behavioral health and substance use disorders:

Except where state law or regulation requires a different definition, “Medically Necessary” or “Medical Necessity” shall mean health 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 patient;
(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 research;
(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.

(Id. at Plan 173.)

         The Plan also gives criteria for admission into a residential treatment facility:

All of the following must be met:
1. All basic elements of medical necessity must be met.
2. One or more of the following criteria must be met:
A. The child/adolescent has been diagnosed with a severe psychiatric disorder that is pervasive and significantly impairs developmentally appropriate functioning. This impairment in function is seen across multiple settings such as; school, home, and in the community, and clearly demonstrates a need for 24-hour supervision and active treatment, OR B. Immediate prior treatment in a more intensive level of care (such as mental health inpatient) has resulted in an acceptable degree of stability. However, the child/adolescent continues to display behaviors that require around-the-clock supervision in a structured setting in order to maintain the safety of the child/adolescent and others.
3. All of the following criteria must be met:
C. The child/adolescent and/or family demonstrate chronic dysfunction, which is likely to respond to multiple therapeutic and family treatment interventions, and all parties commit to active regular treatment participation.
D. The child/adolescent is able to function with age appropriate independence, participate in structured activities in a group environment, and is capable of developing the skills necessary for functioning outside of the residential program.
E. Less restrictive or intensive levels of treatment are not appropriate to meet the individual's needs or have been tried and were unsuccessful.

(Id. at Plan 175 (boldface in original).) Additionally, the Plan lists “Admission Considerations, ” including whether, before admission, “there has been a face-to-face assessment with the child/adolescent and family to determine if this level of care is medically necessary and clinically appropriate.” (Id. at Plan 174.)

         If Cigna denies coverage for treatment, the Plan has two levels of review. First, a claimant may file an internal appeal with Cigna. Second, if dissatisfied with Cigna's decision on appeal, a claimant may request an external review by an independent review organization, or IRO.

         M.W.'s Admission to Diamond Ranch Academy

         M.W.'s behavioral problems began at a young age. From ages four to eight, he experienced recurring episodes of rage that led to his being sent home from day care, his suspension from first grade, and several inpatient hospitalizations at Nachtaug Hospital in Connecticut. During one such episode, at age five, M.W. tried to stab another child in the neck with a pair of scissors. While hospitalized, doctors diagnosed and treated M.W. for bipolar disorder, attention deficit/hyperactivity disorder, oppositional defiant disorder, and frontal lobe seizures.

         M.W. continued to struggle in elementary school. In 2006, at around age seven, M.W. was placed in Nachtaug Hospital's outpatient school called Hickory Street. While there, he attempted to stab a therapist with a pencil and was again hospitalized. In November 2007, he was transferred to Meridell Children's Hospital in Texas, where he continued inpatient treatment and therapy until March of 2008. From 2009 to 2012, M.W. attended Stott Elementary School, where he again experienced outbursts of rage. During one instance, he tried to climb out of the window of a moving bus. During another, he ran out of school and across busy streets until caught and restrained by police.

         After M.W. ran away from school, his doctor changed his medication. By Sandy's account, the change worked. But M.W.'s behavioral problems returned in 2013. According to Sandy, M.W. “again became physically aggressive, verbally abusive and refused to take his medication.” (Admin. R. at ¶ 119.) He threatened to kill Sandy and Colby when angry, and, at one point, ...


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