United States District Court, D. Utah, Central Division
SANDY JO H., individually and as guardian of COLBY W. and M.W., minors, Plaintiff,
CIGNA BEHAVIORAL HEALTH, and THE INTERVENTION INC. MEDICAL BENEFIT PLAN, Defendants.
ORDER AND MEMORANDUM DECISION
CAMPBELL U.S. DISTRICT COURT JUDGE
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
Intervention, Inc. Medical Benefit Plan
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
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
(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
(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.)
Plan also gives criteria for admission into a residential
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
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
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
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.
Admission to Diamond Ranch Academy
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.
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.
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, ...