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Mike G. v. Bluecross Blueshield of Texas

United States District Court, D. Utah

June 4, 2019

MIKE G. and DANA M., individually and as guardians of A.G., a minor, Plaintiffs,
v.
BLUECROSS BLUESHIELD OF TEXAS, Defendant.

          MEMORANDUM DECISION AND ORDER

          Ted Stewart United States District Judge.

         District Judge Ted Stewart This matter is before the Court on cross Motions for Summary Judgment. For the reasons discussed below, the Court will grant in part and deny in part both Motions.

         I. BACKGROUND

         Plaintiffs Mike G. and Dana G., and their daughter A.G. (collectively, “Plaintiffs”) had health insurance coverage under a group health benefits plan (the “Plan”) insured by Defendant Blue Cross Blue Shield of Texas (“Blue Cross”). The Plan is an employee welfare benefits plan under the Employee Retirement Income Security Act (“ERISA”).

         A. THE PLAN TERMS

         The Plan requires that “[a]ll services and supplies for which benefits are available under the Plan must be Medically Necessary.”[1] Benefits are not available for “[a]ny services or supplies which are not Medically Necessary and essential to the diagnosis or direct care and treatment of a sickness, injury, condition, disease, or bodily malfunction.”[2]

         Medically Necessary or Medical Necessity means those services or supplies covered under the Plan that are:

1. Essential to, consistent with, and provided for the diagnosis or the direct care and treatment of the condition, sickness, disease, injury, or bodily malfunction; and
2. Provided in accordance with and are consistent with generally accepted standards of medical practice in the United States; and
3. Not primarily for the convenience of the Participant, his Physician, Behavioral Health Practitioner, the Hospital, or the Other Provider; and
4. The most economical supplies or levels of service that are appropriate for the safe and effective treatment of the Participant. When applied to hospitalization, this further means that the Participant requires acute care as a bed patient due to the nature of the services provided or the Participant's condition, and the Participant cannot receive safe or adequate care as an outpatient.
The medical staff of BCBSTX shall determine whether a service or supply is Medically Necessary under the Plan and will consider the views of the state and national medical communities, the guidelines and practices of Medicare, Medicaid, or other government-financed programs, and peer reviewed literature. Although a Physician, Behavioral Health Practitioner or Professional Other Provider may have prescribed treatment, such treatment may not be Medically Necessary within this definition.[3]

         The Plan provides that “Medically Necessary Mental Health Care or treatment of Serious Mental Illness in a Psychiatric Day Treatment Facility, a Crisis Stabilization Unit or Facility, or a Residential Treatment Center for Children and Adolescents, in lieu of hospitalization, shall be Inpatient Hospital Expense.”[4] However, “[r]esidential treatment centers for mental health services other than treatment for children and adolescents” are excluded.[5]

         Mental Health Care includes:

1. The diagnosis or treatment of a mental disease, disorder, or condition listed in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, as revised, or any other diagnostic coding system as used by the Carrier, whether or not the cause of the disease, disorder, or condition is physical, chemical, or mental in nature or origin;
2. The diagnosis or treatment of any symptom, condition, disease, or disorder by a Physician, Behavioral Health Practitioner or Professional Other Provider (or by any person working under the direction or supervision of a Physician, Behavioral Health Practitioner or Professional Other Provider) when the Eligible Expense is:
a. Individual, group, family, or conjoint psychotherapy,
b. Counseling,
c. Psychoanalysis,
d. Psychological testing and assessment,
e. The administration or monitoring of psychotropic drugs, or
f. Hospital visits or consultations in a facility listed in subsection 5, below;
3. Electroconvulsive treatment;
4. Psychotropic drugs;
5. Any of the services listed in subsections 1 through 4, above, performed in or by a Hospital, Facility Other Provider, or other licensed facility or unit providing such care.[6]

         Serious Mental Illness, includes, among other things, depression in childhood and adolescence.[7]

         A Psychiatric Day Treatment Facility is defined as “an institution which is appropriately licensed and is accredited by the Joint Commission on Accreditation of Healthcare Organizations as a Psychiatric Day Treatment Facility for the provision of Mental Health Care and Serious Mental Illness services to Participants for periods of time not to exceed eight hours in any 24hour period.”[8] A Crisis Stabilization Unit or Facility “means an institution which is appropriately licensed and accredited as a Crisis Stabilization Unit or Facility for the provision of Mental Health Care and Serious Mental Illness services to persons who are demonstrating an acute demonstrable psychiatric crisis of moderate to severe proportions.”[9] Finally, a Residential Treatment Center for Children and Adolescents is “a child-care institution which is appropriately licensed and accredited by the Joint Commission on Accreditation of Healthcare Organizations or the American Association of Psychiatric Services for Children as a residential treatment center for the provisions of Mental Health Care and Serious Mental Illness services for emotionally disturbed children and adolescents.”[10]

         B. TREATMENT AT OUTBACK

         A.G. received treatment at Outback Therapeutic Expeditions (“Outback”), an outdoor wilderness therapy program in Lehi, Utah, from February 7, 2014, to April 11, 2014. A.G. did poorly at Outback and she was discharged from the program to begin treatment at Uinta Academy (“Uinta”). While en route to Uinta, A.G. ran away from her parents and spent the night in a hotel room with a group of men she did not know.

         Blue Cross denied benefits for Outback on September 10, 2014. The Explanation of Benefits identified the type of treatment A.G. received as “residential” and stated that “[t]his expense/service is not covered under the terms and conditions of your Health Care Plan. No. payment can be made.”[11] Plaintiffs appealed the denial, but Blue Cross did not respond.

         C. TREATMENT AT UINTA

         After being discharged from Outback, A.G. was admitted to Uinta, a residential treatment center in Wellsville, Utah. Upon admission, A.G. was diagnosed with cyclothymic disorder, oppositional defiant disorder, eating disorder not otherwise specified, and mathematics disorder.[12] It was noted that she had a long history of parental conflict, compulsive lying, running away, defiant behavior, and depression.[13] It was further noted that A.G. had no insight into her impulsive behavior and tended to avoid taking any accountability for it.[14] As a result, she needed to be monitored closely.[15]

         Dr. Bret Marshall conducted a psychiatric evaluation of A.G. on April 30, 2014.[16] Dr. Marshall noted that A.G.'s behaviors had become increasingly egregious, including threatening suicide and running away from home.[17] As a result, it was determined that she needed extended structure and help.[18] At that point, A.G. denied any thoughts of suicide, self-harm, or homicide.[19] She had no hallucinations or delusions, and her judgment was fair.[20] However, her insight was limited.[21] Dr. Marshall diagnosed A.G. with cyclothymic disorder, disruptive mood dysregulation disorder, alcohol related neurodevelopmental disorder, and specific learning disorder with impairment in mathematics, and prescribed medication.[22]

         On May 7, 2014, A.G. reported to Dr. Marshall that it was easier for her to focus in school and that she had been doing better managing her impulses.[23] A.G. reported a good family visit.[24] Dr. Marshall noted that A.G.'s therapist at Uinta, Liz Beers, agreed that A.G. was doing better overall.[25] Dr. Marshall continued A.G. on her current medications.

         By June 4, 2014, Dr. Marshall noted that A.G. struggled with respect and often laid in her bed, refusing to do anything.[26] Ms. Beers noted that A.G.'s irritability was very high.[27] As a result, Dr. Marshall increased her dose of Lamictal.[28]

         In June 2014, A.G. had a “difficult visit” with her parents, which resulted in her parents calling Uinta staff when she became nonresponsive.[29] However, she had a good visit with her family in July and had an overnight visit.[30] She also went on a trip to Jackson Hole, Wyoming.[31]

         On July 2, 2014, when A.G. saw Dr. Marshall again, she stated that she was “good” and that “[t]his month has been really good.”[32] Dr. Marshall noted that A.G.'s sleep, appetite, and energy were all good.[33] Uinta staff also noted that A.G. was managing her frustration a lot better.[34]

         Therapy treatment notes from August 8, 2014, state that A.G. received praise for working through her frustration.[35] On August 11, 2014, it was noted that she participated appropriately in group therapy.[36] A Treatment Plan Review completed on August 13, 2014, noted that A.G. had “not been out of instructional control since late June 2014, and has done this by working to regulate her irritability and anger response by use of deep breathing, goal setting, and personal mantras.”[37]

         A.G. again saw Dr. Marshall on August 13, 2014. A.G. stated that she was “good” and was “doing pretty good in treatment.”[38] A.G. stated that she believes she focuses effectively and, when frustrated, “doesn't blow up like I used to.”[39] “I observe, describe, and participate.”[40]Uinta staff reported that they had seen “good improvement” in A.G. over the past couple of months and noted that she manages her impulses much more effectively.[41] Ms. Beers agreed and noted that A.G. showed a strong amount of effort and her accountability was improving.[42] That same day, A.G. had a positive attitude during and participated in group therapy discussions.[43]

         On August 21, 2014, A.G. was “positive” and “engaged” at a group therapy session.[44]On August 26, 2014, A.G. had a “pleasant” attitude during group therapy and was able to talk about and work through her frustration.[45] A.G. had a difficult visit with her mother and grandmother in August, which resulted in her mother calling A.G.'s therapist when she became argumentative at a restaurant.[46]

         On September 5, 2014, A.G. became nonresponsive during a family therapy session and refused to participate in stress management.[47] Treatment notes from September 9, 2014, indicate that A.G. had engaged in self-harm over the weekend, though she took accountability for her behavior.[48]

         Dr. Marshall saw A.G. on September 10, 2014. A.G. reported that she was “good, ” but admitted that a few days earlier she was “stressed” and “self-harmed.”[49] While she noted she had been feeling anxious, she also stated that she had done “pretty good” that day and the day before.[50] Uinta staff reported that A.G. would do well for a certain period of time, but would give up if she did not see the results she wanted.[51] Ms. Beers noted that she was working with A.G. on this issue in therapy.[52]

         On September 28, 2014, therapy notes indicate that A.G. made threats, but that she stated that she did not feel like harming herself in any way and signed a no self-harm contract.[53] A.G. was aware of her pattern to escalate and make threats when she is upset and committed to working to change that pattern.[54]

         At some point in September 2014, A.G. went to Yellowstone National Park. In October, she went off campus with her parents for two overnights.[55]

         On October 7, 2014, A.G. reported to Dr. Marshall that she was “doing pretty good” and “feeling happier.”[56] Dr. Marshall noted that they had prescribed clonidine and A.G. noticed that she was more positive taking that.[57] Uinta staff noted that they had “seen a shift” with A.G.[58]Her mood was not hyper, which was a benefit, and she “has been doing really well.”[59] Ms. Beers also reported an improved ability to focus.[60] Dr. Marshall noted that A.G. had a bright affect, and was linear, polite, and focused.[61] He noted that A.G. had “[i]mproved” and made no change in her medication.[62] A therapy progress note from that day indicates that A.G. “reports having less difficulty and negativity in the mornings and improved ability to recognize when she needs to use her stress management skills.”[63]

         On October 10, 2014, Ms. Beers wrote a letter in connection with Plaintiffs' appeal of the denial of benefits.[64] Ms. Beers noted that A.G. suffered from a lack of insight and had multiple relapses into poor behavior.[65] She struggled with her relationship with her parents and had engaged in self-harming behavior.[66] Overall, A.G. “has not shown sustained ability to control her impulses, communicate honestly, or even keep herself physically safe without high levels of structure and therapeutic support.”[67] Ms. Beers believed that if A.G. stepped down to a lower level of care, “she would be uncontrollable, unpredictable, and likely to harm herself or someone else.”[68] As a result, her continued “need for residential treatment is great if she is to succeed through to adulthood.”[69]

         On October 28, 2014, group therapy notes indicate that A.G. struggled to work cooperatively.[70] Individual therapy notes state that A.G. used her skills to contribute to a “positive family weekend.”[71] Treatment notes from the following day indicate that A.G. was doing well.[72] On October 30, 2014, A.G. was positive and engaged in group therapy.[73] That same day, her family reported an “excellent visit” and her parents “stated there is a visible change in her.”[74]

         The following two days, A.G. was “out of instructional control” “due to arguing with staff.”[75] However, “she was able to turn things around by using her mindfulness and distress tolerance skills.”[76]

         On November 4, 2014, A.G. was “calm and relaxed” during “a potentially frustrating situation.”[77] On November 11, 2014, A.G. had a “pleasant” attitude during group therapy.[78] The same was true on November 18, 2014.[79]

         On November 20, 2014, Ms. Beers noted that A.G. “continues to struggle with emotional regulation” and “has not demonstrated an ability to generalize her skills in her home environment.”[80] Despite this, A.G. left campus the following day with her mother for a visit.[81]At her therapy session on November 25, 2014, A.G. reported that she had a good visit with her mother.[82] While she became frustrated on three occasions, she was able to accept feedback and keep herself calm.[83]

         On December 3, 2014, A.G. met with Dr. Marshall for medication management and she was continued on her medication.[84] The following day, she was engaged and participatory in group therapy.[85]

         On December 11, 2014, A.G. shut down emotionally at the end of a family therapy session after sharing a previously undisclosed trauma to her parents.[86] Later that day, she was irritable during group therapy.[87] On the days following, her attitude was pleasant and positive.[88]On December 16, 2014, A.G. reported symptoms of hypomania.[89]

         A.G. returned home in December 2014 for the Christmas holiday.[90] Upon her return to Uinta, she “reported she had a good visit.”[91] Though she became frustrated on one occasion, she was able to calm herself down.[92]

         On January 8, 2015, A.G. was informed that her parents' relationship was ending.[93] She “was able to stay engaged, manage her emotions, and stay mindful about the news.”[94] During a family therapy session with her father that day, A.G. “was able to stay present throughout the session.”[95] “She was very mature, ” she “did not shut down or become angry to the point where she had to leave, ” and “she was calm and collected and did not lash out.”[96] In a session with her mother and sister, A.G. remained calm throughout the session, was able to handle uncertainty, and expressed positivity.[97]

         A.G. met with Dr. Marshall for medication management on January 13, 2015. A.G. reported a good home visit, but stated that the past week had been rough.[98] Therapy progress notes from January 14, 2015, indicate that A.G. was experiencing increased frustration and struggling to deal with it.[99]

         During a family therapy session with her father on January 29, 2015, A.G. was “praised for her maturity.”[100] A few days later, she indicated that she was feeling positive about her relationship with her father.[101]

         During a medication management appointment with Dr. Marshall on February 10, 2015, A.G. reported that she was doing well managing her frustration.[102] On February 13, 2015, A.G. had a negative attitude during group therapy.[103]

         In February 2015, A.G. went on a home visit. Upon her return, she stated that she felt she did well but could use more work on accepting “no” for an answer.[104]

         On March 9, 2015, A.G. had a depressed attitude and was disengaged during group therapy.[105]

         In her March medication management appointment with Dr. Marshall, A.G. reported having a rough night and was having trouble dealing with her frustrations.[106] Uinta staff confirmed that they noticed an increase in A.G.'s frustration level and that she was having trouble tolerating difficulties.[107] Dr. Marshall adjusted A.G.'s medication.[108]

         On March 13, 2015, A.G. initially had a negative attitude in group therapy, but “moved through some of her emotions and became more positive.”[109] On March 17, 2015, A.G. reported better sleep, better impulse control, better ability to accept consequences and feedback, and decreased irritability since her medication adjustment.[110]

         In late March, A.G had a visit with her father. On March 23, 2015, she reported that the “visit went very well and that she has more confidence in her and her dad's relationship.”[111] On March 30, 2015, A.G. was “very positive.”[112] She was positive and engaged during group therapy.[113]

         On April 1, 2015, A.G. struggled to accept feedback and consequences without expressing aggression or anger.[114]

         On June 1, 2015, A.G. struggled with her affect.[115] By the next day, she was in a positive mood and was happy and helpful with her peers.[116] That night, however, she struggled again.[117]On June 3, 2015, A.G. struggled and was feeling discouraged.[118] On June 4, she was unable or unwilling to engage in group therapy.[119] On June 5, A.G. did well listening and accepting feedback, and was mostly positive.[120] On June 8, 2015, A.G. was happy, had a positive affect, stayed positive, and was encouraging with her peers.[121] On June 11, 2015, A.G. had a positive affect, expressed feeling better, and was assertive and responsible.[122] On June 16, 2015, Uinta staff stated that A.G. did a great job accepting feedback and asking for help.[123]

         In mid-June, A.G. left for a home visit. On June 26, 2015, she reported the visit a positive experience with minimal arguing.[124] She reported “feeling much better.”[125] She did well for the next several days.[126] However, she began to struggle after hearing that her family was going to put her dog down.[127]

         A.G. was discharged from Uinta on December 6, 2015. However, the record before the Court does not contain treatment notes after June 30, 2015.

         D. CLAIM PROCESS FOR UINTA

         As stated, A.G. was admitted to Uinta on April 13, 2014. On April 21, 2014, Kelly Walker, a Behavioral Health Care Coordinator at Blue Cross, conducted a review of A.G.'s claim and spoke to Ms. Beers. Ms. Walker noted a history of depression and of threating self-harm and suicide.[128] Ms. Walker noted that A.G. had no insight and poor judgment and impulse control.[129] Ms. Walker stated that A.G. was initially on an “arms length safety precaution at admission, ” and was now on “elevated eye sight precautions/constant visual unless in bathroom.”[130] Ms. Kelly indicated that A.G. met the Milliman Care Guidelines as “evidenced by multiple areas of impairment in daily living, need for medication management and mood stabilization/safety planning.”[131] As a result, Blue Cross authorized fifteen days of residential treatment.[132]

         On April 28, 2014, Ms. Walker conducted another call with Ms. Beers. Ms. Walker noted that A.G. had increasing irritability and impulsivity.[133] She had labile affect, irritable mood, and very poor insight/judgment.[134] Ms. Walker noted that A.G. was extremely impulsive, was a flight risk, and had poor insight into her actions and consequences.[135] Ms. Walker also noted that A.G. would see a psychiatrist that week for a medication evaluation.[136] Blue Cross authorized an additional four days of residential treatment, citing the Milliman Care Guidelines and the “severe dysfunction in the family and need for medication evaluation to be completed.”[137]

         Blue Cross authorized an additional seven days on May 1, 2014, noting the need to monitor medications, mood stabilization, and multiple areas of dysfunction in daily living.[138]

         On May 9, 2014, Ms. Walker noted that A.G. continued to have an extreme level of irritability.[139] She had a visit with her parents, but it went poorly.[140] A.G. was considered an extreme flight risk, lacked insight, and had continued opposition to treatment.[141] Based on the “Milliman, ASAM and/or TAC CD guidelines, ” an additional day of treatment was authorized.[142] Three additional days were then authorized so a shaping review could be conducted.[143]

         On May 12, 2014, Dr. Clifford Moy, Blue Cross' Medical Director, conducted a shaping review with Dr. Marshall. Dr. Moy found that A.G. met the Milliman Care Guidelines for mental health residential treatment based on “ongoing defiance and medication titration; history [of] higher risk of running away.”[144] As a result, an additional seven days of treatment were authorized.[145]

         By May 19, 2014, the last date of authorized coverage, Blue Cross noted that Plaintiff continued to have a labile mood, irritable affect, a lack of insight, and very poor judgment.[146]The Aerial notes from Blue Cross reflect that A.G. made no progress since the prior review on May 12, was non-compliant with therapy, and was a continued flight risk.[147] Despite this, Ms. Walker found that A.G. did not meet the Milliman Care Guidelines.[148]

         Dr. Moy then conducted a peer-to-peer review. Dr. Moy also noted in his review that there was “no improvement or change” in A.G.'s condition.[149] Dr. Moy found that A.G. had no suicidal or homicidal ideation and no psychosis. He further noted that she was not aggressive. Dr. Moy found that A.G. may require a structured living situation, but did not appear to benefit from treatment. Thus, residential care was not required, and mental health partial hospitalization/day treatment was recommended. As a result, Blue Cross determined that A.G. did not meet the Milliman Care Guidelines criteria for residential treatment and denied further benefits.[150]

         On May 20, 2014, Blue Cross issued its initial denial letter to Plaintiffs.[151] The letter explained: “You were not reported as being an imminent danger to self or others. There was no report of psychosis or mania. From the clinical evidence, you can be safely treated in a less restrictive setting such as MH Partial Hospitalization/Day Treatment (PHP).”[152]

         Plaintiffs submitted a first level appeal of the Uinta denial on November 13, 2014. On December 4, 2014, Dr. Frank Webster, the Senior Medical Director for Behavioral Health for Blue Cross, conducted a paper review.[153] Dr. Webster noted that he reviewed the Aerial notes and the notes from Uinta, as well as letters from A.G.'s outpatient providers.[154] Dr. Webster concluded:

Patient Does not meet criteria for RTC based on Milliman guidelines. Patient is not suicidal, homicidal, or psychotic. She is not aggressive. Patient appears to be functioning fairly well and appears to be at her baseline level of functioning. Patient has some chronic maladaptive behaviours, [sic] and impulsive behaviours [sic] as well that place her a [sic] at a chronically elevated risk for impulsive behaviour, [sic] but these do not occur at a frequency that require a residential level of care, and has no acute risk of harm to self or others. Patient continues to be oppositional with family at times. She is occasionally oppositional in the program (these behaviours [sic] appear infrequent), but not at level that could not be managed as an outpatient. It appears that she could be managed in a lower level of care such as outpatient therapy with intensive family therapy.[155]

         On December 4, 2014, Blue Cross issued its denial letter, rejecting Plaintiffs' first level appeal.[156] The denial letter stated that A.G. did not meet the Milliman Care Guidelines for mental health residential treatment for the following reasons:

You were not suicidal, homicidal or psychotic. You were not aggressive. You appeared to be functioning fairly well, and at the baseline level of functioning. You had some chronic maladaptive behaviours [sic], and impulsive behaviours [sic] as well that placed you at a chronically elevated risk for impulsive behaviour, [sic] but these do not occur at frequency that require residential level of care. You had no acute risk of harm to yourself or others. You continued to be oppositional with family at times. You were occasionally oppositional in the program (these behaviours [sic] appear infrequent), but not at a level that could not be managed as an outpatient. It appeared that you could be managed in a lower level of care such as outpatient therapy with intensive family therapy. From the clinical evidence you could have been safely treated in a less restrictive setting such as MENTAL HEALTH PARTIAL HOSPITALIZATION/DAY TREATMENT (PHP).[157]

         On January 29, 2015, Plaintiffs requested an independent external review by an Independent Review Organization (“IRO”). On March 3, 2015, the IRO, Core 400 LLC, issued a decision upholding Blue Cross' denial of benefits for A.G.'s treatment at Uinta. The decision stated:

By the date of service, 05/20/14, the patient's behavior had stabilized. The patient denied suicidal and homicidal ideation. There is no indication that the patient was [an] imminent risk of harm to herself or others. The patient was not psychotic. The patient was not aggressive at that time. Although the patient continued with some chronic maladaptive behaviors and impulsive behavior, these incidents did not occur at a frequency that would require this level of care. The submitted records indicate that the patient could have been effectively treated at a lower level of care as of the date in question. Discharge guidelines indicate that residential care is no longer necessary due to adequate patient stabilization or improvement as indicated by all of the following: risk status acceptable, functional status acceptable and medical needs manageable. The submitted clinical records indicate that these criteria had been met as of 05/20/14. As such, it is the opinion of the reviewer that the request for mental health residential treatment 5/20/2014 forward is not recommended as medically necessary and the prior denials are upheld.[158]

         II. STANDARD OF REVIEW

         In an ERISA case, “summary judgment is merely a vehicle for deciding the case; the factual determination of eligibility for benefits is decided solely on the administrative record, and the non-moving party is not entitled to the usual inferences in its favor.”[159]

         The parties agree that the Court should employ a de novo standard of review. The Court will accept this stipulation. Under the de novo standard, the Court's task “is to determine whether the administrator made a correct decision.”[160] Thus, the question “is whether the plaintiff's claim for benefits is supported by a preponderance of the evidence based on the district court's independent review.”[161]

         III. DISCUSSION

         A. OUTBACK

         The Plan provides that “Medically Necessary Mental Health Care or treatment of Serious Mental Illness in a Psychiatric Day Treatment Facility, a Crisis Stabilization Unit or Facility, or a Residential Treatment Center for Children and Adolescents, in lieu of hospitalization, shall be Inpatient Hospital Expense.”[162] However, “[r]esidential treatment centers for mental health services other than treatment for children and adolescents” are excluded.[163] Here, while Outback provides residential treatment, there is no evidence that Outback is a Residential Treatment Center for Children and Adolescents as defined by the Plan.

         A Residential Treatment Center for Children and Adolescents is “a child-care institution which is appropriately licensed and accredited by the Joint Commission on Accreditation of Healthcare Organizations or the American Association of Psychiatric Services for Children as a residential treatment center for the provisions of Mental Health Care and Serious Mental Illness services for emotionally disturbed children and adolescents.”[164] There is no dispute that Outback was not so licensed and accredited. Therefore, it does not fall within the Plan terms for coverage, thereby becoming excluded under the residential treatment center exclusion.

         Plaintiffs argue that coverage at Outback was appropriate because wilderness programs are not specifically excluded under the Plan. The fact that there is no specific exclusion for wilderness programs is irrelevant. Coverage for treatment at Outback was not denied because Outback was a wilderness program. Rather, coverage was denied because Outback was not a residential treatment center as defined by the Plan and, therefore, A.G.'s treatment there was not covered by the Plan.

         Plaintiffs further argue that A.G.'s treatment at Outback should have been covered because the Plan's definition of Mental Health Care includes the type of treatment she received at Outback. Plaintiffs' argument conflates the definition of certain defined terms with the coverage of services. While the definition of Mental Health Care is broad, the definition does not necessarily equate to coverage. To determine coverage, the Court must look not just to the definitions, but also to the covered medical services set out in the Plan. For example, Plaintiffs cite to Paragraph 2 of the definition of Mental Health Care to support their claim, but this paragraph requires an Eligible Expense.[165] Eligible Expense, in turn, is defined as “Inpatient Hospital Expenses, Medical-Surgical Expenses, Extended Care Expenses, or Special Provisions Expenses, as described in this Benefit Booklet.”[166] As stated, Inpatient Hospital Expense does include Mental Health Care or treatment of a Serious Mental Illness.[167] However, that coverage only applies to a Psychiatric Day Treatment Facility, a Crisis Stabilization Unit or Facility, or a Residential Treatment Center for Children and Adolescents.[168] There is no evidence that Outback fits any of these definitions.

         Further, under Paragraph 5 of the definition of Mental Health Care, coverage is limited to mental health care performed in or by a Hospital, Facility Other Provider, or other licensed facility or unit providing such care.[169] There is no evidence that Outback is a Hospital as defined by the Plan. The definition of “Facility Other Provider” is also limited and would include, as relevant here, a Psychiatric Day Treatment Facility, a Crisis Stabilization Unit or Facility, or a Residential Treatment Center for Children and Adolescents.[170] Again, there is no evidence that Outback falls into one of these categories. While the argument could be made that Outback is an “other licensed facility or unit providing such care, ” that term must be read in conjunction with the rest of the Plan limitations.[171] By focusing exclusively on the definitions of certain terms, Plaintiffs fail to address whether the treatment A.G. received was a covered medical expense under the terms of the Plan. For the reasons set forth above, the Court concludes that it is not.

         Plaintiffs further argue that the Court cannot consider Defendant's arguments made with respect to their denial of coverage for treatment at Outback because it did not respond to their first level appeal. “A plan administrator is required by statute to provide a claimant with the specific reasons for a claim denial.”[172] “Thus, the federal courts will consider only those rationales that were specifically articulated in the administrative record as the basis for denying a claim.”[173] “A plan administrator may not treat the administrative process as a trial run and offer a post hoc rationale in district court.”[174]

         Here, Blue Cross denied coverage for Outback because it was not covered under the terms of the Plan. Blue Cross makes the same argument here. Thus, it is proper to consider the arguments made by Blue Cross in relation to this claim. This is not a situation where “[t]he specific reasons and specific provisions supporting Defendant's . . . argument have changed” and it has presented an “after-the-fact interpretation of an entirely different section of the Plan.”[175]Therefore, Plaintiffs' argument must be rejected and the Court will uphold the denial of benefits for Outback.

         B. UINTA

         As discussed above, A.G. resided at Uinta from April 13, 2014, to December 6, 2015. Blue Cross approved A.G.'s treatment at Uinta from April 13, 2014, to May 19, 2014. After that date, Blue Cross determined that further residential treatment was no longer medically necessary. Plaintiffs argue that Blue Cross' declination of coverage beyond May 19, 2014, was incorrect.

         Blue Cross primarily used the Milliman Care Guidelines in determining the medical necessity of A.G.'s treatment at Uinta. The Milliman Care Guidelines provide that admission to residential acute level of care is appropriate as indicated by all of the following:

▪ Around-the-clock behavioral care is necessary for treatment because of 1 or more of the following:
• Imminent danger to self is present due to 1 or more of the following:
o Imminent risk for recurrence of Suicide attempt or act of serious Harm to self is present as indicated by ALL of the following:
▪ There has been a very recent Suicide attempt or deliberate act of serious Harm to self.
▪ There has not been Sufficient relief of the factors that precipitated the attempt or act.
o Current plan for suicide or serious Harm to self is present.
o Command auditory hallucinations for suicide or serious Harm to self are present. o The patient is engaging in dangerous behavior, or has persistent Thoughts of suicide or serious Harm to self, or suicide trigger state without formed thoughts, that cannot be adequately monitored at lower level of care as indicated by 1 or more of the following:
▪ The necessary child or adolescent behavioral care (such as the required provide or lower level facility) is not available or is insufficient.
▪ Severe conflict in family environment or other inadequacy in patient support system is present.
▪ Patient characteristic such as high impulsivity, unreliability, or extreme agitation with desperation are present.
▪ Ruminative flooding; uncontrollable and overwhelming profusion of negative thoughts are present.
▪ Frantic hopelessness; fatalistic conviction that life will not improve along with oppressive sense of entrapment and doom is present.
• Imminent danger to others due to 1 or more of the following:
o Imminent risk for recurrence of an attempt to seriously Harm another is present as indicated by ALL of the following:
▪ There has been a very recent attempt to seriously Harm another.
▪ There has not been Sufficient relief of the factors that precipitated the attempt or act.
o Current plan for homicide or serious Harm to another is present.
o Command authority hallucinations or paranoid delusions contributing to risk for homicide or serious Harm to another are present.
o The patient has persistent thoughts of, or violent impulsive act that could likely result in, homicide or serious Harm to another that cannot be adequately monitored at lower level of care as indicated by 1 or more of the following:
▪ The necessary child or adolescent behavioral care (such as the required provide or lower level facility) is not ...

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