United States District Court, D. Utah
MEMORANDUM DECISION AND ORDER
STEWARTR UNITED STATES DISTRICT JUDGE.
matter is before the Court on cross Motions for Summary
Judgment. For the reasons discussed below, the Court will
grant Defendants' Motion and deny Plaintiffs' Motion.
Nicole N. (“Nicole) was a participant of the Granite
Transformations health benefit plan (the “Plan”),
an employee welfare benefit plan governed by ERISA.
Nicole's son, Nicholas, was covered under the Plan.
Nicholas was admitted to Catalyst Residential Treatment
Center (“Catalyst”) on August 22, 2014. Catalyst
is a residential treatment facility providing mental health
care to adolescent boys who have been diagnosed with mental
health or substance use disorders.
submitted claims for Nicholas' treatment at Catalyst and
Defendant denied the claims because Plaintiffs had not
obtained prior authorization for Nicholas' treatment.
After two levels of appeal and a review by an independent
third-party reviewer, Coventry maintained its denial of
coverage. Plaintiffs now seek review.
Plan includes various prior authorization requirements. Prior
authorization means the “[v]erification of Medical
Necessity by the Health Plan, for certain services, supplies,
equipment, drugs or procedures to be received by a
Member.” Relevant here, the Plan states,
“[i]f Your Agreement provides Coverage under a Mental
Disorder and Substance-Related Disorder Rider, Prior
Authorization must be obtained from the telephone number
listed on Your ID card.” The Plan goes on to warn that the
“[f]ailure to provide sufficient notice or to obtain
Prior Authorization when required may result in reduction or
denial of benefits.”
NICHOLAS N.'S TREATMENT AT CATALYST
was admitted to Catalyst on August 22, 2014, to receive
mental health and substance abuse treatment. Nicholas
remained at Catalyst until August 2015, when he was
successfully discharged to his home. Catalyst is considered a
“Non-Participating Provider” under the
September 30, 2014, Nicole contacted Coventry to request
information to seek reimbursement for Nicholas' treatment
at Catalyst and she was directed to MHNet's website to
obtain the necessary form.
November 10, 2014, MHNet denied Plaintiffs' claim,
stating that the services were not authorized and the charged
amount was above the payable rate.
April 3, 2015, Nicole submitted a first level appeal. On May
28, 2015, Coventry denied Nicole's first level appeal.
Coventry noted that Catalyst was an out-of-network provider
and prior authorization was required. Because Plaintiffs had
failed to obtain prior authorization, the request for
coverage was denied.
22, 2015, Nicole submitted a second level appeal. As part of
that appeal, Nicole requested a retrospective review. On
January 13, 2016, Coventry upheld the denial, concluding that
residential treatment was not medically necessary.
11, 2016, Nicole submitted a request for an independent
review. On June 28, 2016, the independent review organization