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Doe v. Harvard Pilgrim Health Care, Inc.

United States District Court, D. Massachusetts

October 11, 2017

JANE DOE, Plaintiff,


          Denise J. Casper, United States District Judge.

         I. Introduction

         Plaintiff Jane Doe (“Jane”) has filed this lawsuit against Defendants Harvard Pilgrim Health Care, Inc., and the Harvard Pilgrim PPO Plan Massachusetts, Group Policy Number 0588660000 (collectively “HPHC”) under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132(a)(1)(B), challenging HPHC's partial denial of health insurance benefits for residential mental health treatment. D. 1. Both Jane and HPHC have moved for summary judgment. D. 56; D. 63. For the reasons stated below, the Court ALLOWS HPHC's motion for summary judgment, D. 63, and DENIES Plaintiff's motion for summary judgment, D. 56.

         II. Factual Background

         Unless otherwise noted, all facts are undisputed and are drawn from the administrative record (“AR”) filed by HPHC, D. 36, [1] and the parties' Statements of Facts, D. 56-1; D. 63-1; D. 63-2; D. 63-3; D. 66. As explained further below, the Court will only consider the portions of the record prepared prior to and including March 12, 2013.

         A. Coverage under the Plan

         At all relevant times, Jane was a dependent beneficiary of a participant in an HPHC group health benefit plan (the “Plan”). D. 1 ¶ 4. Her father was a member of the Plan through his employer. D. 1 ¶¶ 6-7. The Plan provides coverage for inpatient care, intermediate care and outpatient mental health care only “to the extent Medically Necessary.” D. 1 ¶ 9; AR at 35-37. “Intermediate mental health care services” that have been deemed medically necessary-a category that includes “[a]cute residential treatment” and partial hospitalization programs-are covered in full. AR at 79. According to HPHC's Benefit Handbook, HPHC “use[s] clinical review criteria to evaluate whether certain services or procedures are Medically Necessary for a Member's care.” AR at 19. The Plan defines medical necessity as follows:

[t]hose health care services that are consistent with generally accepted principles of professional medical practice as determined by whether: (a) the service is the most appropriate supply or level of service for the Member's condition, considering the potential benefit and harm to the individual; (b) the service is known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; and (c) for services and interventions that are not widely used, the use of the service for the Member's condition is based on scientific evidence.

AR at 21-22.

         At the time of Jane's treatment, HPHC contracted with United Behavioral Health (“UBH”) to manage mental health benefits and review initial coverage determinations for HPHC members. D. 63-2 ¶ 7; D. 66 ¶ 7. To determine whether a mental health treatment was medically necessary, HPHC employed UBH's Optum Level of Care Guidelines. D. 56-1 ¶ 2; D. 63-2 ¶ 7. According to the Guidelines, a Residential Treatment Center “provides overnight mental health services to members who do not require 24-hour nursing care and monitoring offered in an acute inpatient setting but who do require 24-hour structure.” AR at 454. Residential Treatment Level of Care requires that one of the following criteria be met:

(1) The member is experiencing a disturbance in mood, affect or cognition resulting in behavior that cannot be safely managed in a less restrictive setting; or (2) There is an imminent risk that severe, multiple and/or complex psychosocial stressors will produce significant enough distress or impairment in psychological, social, occupational/educational, or other important areas of functioning to undermine treatment in a lower level of care; or (3) The member has a co-occurring medical disorder or substance use disorder which complicates treatment of the presenting mental health condition to the extent that treatment in a Residential Treatment Center is necessary.

Id. Additionally, continued treatment must meet six Continued Service Criteria that apply to all levels of care, including, as is relevant here: (6) “The member's current symptoms and/or history provide evidence that relapse or a significant deterioration in functioning would be imminent if the member was transitioned to a lower level of care.” AR at 459.

         Upon receiving a determination from HPHC that certain treatment is not medically necessary, a member may file an appeal. AR at 52. A claimant must file its appeal within 180 days of the date of service. AR at 51. Claimants appealing medical necessity determinations may not appeal through the informal inquiry process; they must file formal appeals. AR at 52. For denials of continued hospital care, members may also request an expedited review of their appeal. AR at 54. If a member appeals a denial of continuation of coverage-and the claimant continues to be a member under the Plan, the service was previously authorized by HPHC and the service was not terminated due to a benefit limit in the Handbook-HPHC continues coverage through the completion of its internal appeal process. AR at 53.

         The HPHC “Appeal Coordinator will try to obtain all information, including medical records, relevant to the appeal.” Id. “The Appeal Coordinator will investigate the appeal and determine if additional information is required from the Member. This information may include medical records, statements from doctors, and bills and receipts for services the Member has received.” Id. Appeals of medical necessity determinations are reviewed by “a health care professional in active practice in a specialty that is the same as, or similar to, the medical specialty that typically treats the medical condition that is the subject of the appeal” and had no participation in any prior decision on the claimant's appeal. Id. HPHC then makes decisions based on the following criteria:

(1) the benefits and the terms and conditions of coverage stated in [the HPHC] Handbook and Schedule of Benefits; (2) the views of medical professionals who have cared for the Member; (3) the views of any specialist who has reviewed the appeal; (4) any relevant records or other documents provided by the Member; and (5) any other relevant information available to us.”

AR at 53-54. If HPHC affirms denial of coverage, the decision is sent to the claimant in a letter also containing “the applicable clinical practice and review criteria information relied on to make the decision, ” the specific reasons the claimant's medical condition, diagnosis and proposed treatment fails to meet these criteria and any alternative treatment options HPHC would cover instead. AR at 54.

         If a formal internal appeal is denied, members may (1) request reconsideration of the medical necessity determination by HPHC's “review committee”; (2) file for external review by an independent organization appointed by the Massachusetts Department of Public Health's Office of Patient Protection (OPP); or (3) pursue legal action. AR at 55. A claimant “must request reconsideration within 15 days of the date of [HPHC's] letter denying the appeal.” Id. A claimant may file for reconsideration before seeking an external review, or if the OPP has determined “an appeal is not eligible for external review, ” but HPHC “will not reconsider an appeal that has been accepted for external review by [OPP].” AR at 56. Claimants may request that the review committee consider additional documents or records for review and may choose to participate in the meeting by phone. AR at 55. The “reconsideration process is voluntary and optional” and is not required for a claimant's exhaustion of administrative remedies. AR at 56.

         A claimant may request external review by filing a request with OPP within four months of receiving written notice of HPHC's appeal decision. Id. The request for external review must include several components, including the OPP application form and a “copy of [HPHC's] final appeal decision.” Id. OPP may also arrange for expedited external review, which a claimant may request by including a written certification by a physician that a delay in providing the relevant treatment would “pose a serious and immediate threat to the health of the insured.” Id. The HPHC Handbook provides that “[t]he decision of the external review agency is binding, and [HPHC] must comply with the decision.” Id.

         B. Jane's Mental Health History

         Jane suffers from schizoaffective disorder, post-traumatic stress disorder (“PTSD”), anxiety, depression, personality disorder and a learning disorder. AR at 610-11. Jane's mental health issues began in 2012, during her freshman year of college. AR at 547, 577, 593. Jane struggled with her college grades and roommate, whose behavior Jane described as “horrible.” AR at 547. At the start of her second semester, Jane “began struggling with depression, anxiety, [and] panic attacks that led her to feeling paralyzed and unable to get out of bed.” AR at 493, 577. She sought help at the college infirmary and was prescribed Zoloft. AR at 493, 577, 593. She then “became agitated” and “experienced sensations in her extremities that felt like snakes working their way to her heart to poison her.” AR at 493, 577. Her medication was changed to Celexa, which worsened her agitation and delusions. AR at 493, 593.

         In March 2012, Jane withdrew from her classes and returned home. AR at 547, 577, 593. She was hospitalized for several days at McLean Hospital, where her medications were switched to a combination of Abilify and Wellbutrin, which relieved her of her delusions. AR at 577, 593; D. 56-1 ¶ 34; D. 63-3 ¶ 34. Her anxiety and depression, however, persisted. AR at 593. Jane continued outpatient treatment with Audrey Rubin, M.D., who identified Jane's symptoms as acute psychosis, accompanied by a history of sexual trauma-a result of bullying by female peers at summer camp at age twelve-and dyslexia. AR at 493, 577-78, 593, 600-01; D. 56-1 ¶ 36; D. 63-3 ¶ 36. Following a stable period, Jane again became psychotic that summer, and at the direction of auditory hallucinations telling her to kill herself, went to the roof of her family home. AR at 493, 578. She considered jumping, but returned downstairs, concerned about upsetting her family. Id. She was again hospitalized at McLean for one week in June 2012, where she was diagnosed with psychotic disorder NOS and borderline personality disorder. AR at 177-80, 493.

         Jane returned to college that fall. AR at 578, 593. Following the Thanksgiving holiday, which she spent at home, Jane returned to school and experienced “what she described as a hypomanic or manic episode.” Id. She began hearing auditory hallucinations and having suicidal ideations. AR at 485, 510, 668. Her roommates and friends brought her to the emergency room. AR at 593. She then experienced a series of conflicts with her peers. AR at 493, 578, 593. Jane's father came to her college for a week to support her attempt to complete the semester. AR at 493, 578, 602. She began Seroquel in December 2012. AR at 510. In January 2013, Dr. Rubin referred her to the Austen Riggs Center (“Riggs”) for acute psychiatric residential treatment. AR at 483.

         C. Jane's Clinical Treatment at Riggs

         On January 17, 2013, Jane was admitted to Riggs, an out-of-network facility, for residential treatment. Id. At this time, HPHC's behavioral health administrator, UBH, authorized coverage for her treatment. AR at 226. HPHC provided coverage for Jane's first few weeks at Riggs, until February 12, 2013, when HPHC, on appeal, upheld its denial of continued coverage for Jane's residential treatment. AR at 441. Jane nevertheless remained at Riggs until June 18, 2013. D. 56-1 ¶ 26; D. 63-3 ¶ 26. On June 18th, Jane was discharged for inpatient treatment at Berkshire Medical Center following an escalation of her symptoms, where she remained for six days. Id. Jane seeks benefits payments for her residential treatment at Riggs from February 13, 2013 through June 18, 2013. D. 56 at 1.

         1. Jane's admission to Riggs on January 17, 2013

         Upon admission to Riggs, Jane met with David Flynn, M.D., who conducted Jane's initial clinical assessment. AR at 485-91. Dr. Flynn documented Jane's diagnosis as psychotic disorder NOS, mood disorder NOS and non-verbal learning disorder. AR at 487. He listed Jane's “symptoms which mitigate against successful outpatient treatment” as including suicidal behavior, self-destructive behavior, inability to live autonomously, depression and anxiety. AR at 487-89. Jane's medication regimen at the time of admission included Lamictal, Abilify and Seroquel. AR at 486. Dr. Flynn noted that Jane “denied current suicidal ideation, intent, or plan.” Id. He deemed her competent to make the decision to seek treatment in an open setting. AR at 486, 488. Dr. Flynn recommended the IRP-G treatment plan, which revolves around group therapy and includes, among other things, psychotherapy four times per week and 24-hour nursing observation. AR at 490. He noted Jane's “[a]nticipated length of stay” was “[s]ix weeks evaluation and treatment admission with longer term treatment possible. [Jane] and her mother are anticipating 4-6 month stay but are open to longer treatment if indicated.” Id. Dr. Flynn reported he discussed with Jane “the possibility of her deferring admission today and coming back after the long weekend, but [Jane] ultimately decided to accept admission today.” Id.

         On the date of her admission to Riggs, Jane also met with therapist Sharon Krikorian, Ph.D., Jane's treating therapist at Riggs, who recommended a comprehensive evaluation and treatment. AR at 494, 749. On that date, Dr. Krikorian reported Jane “denie[d] current thoughts of suicide or self harm and was able to state clearly and with good eye contact that she could come to nursing if this changes.” AR at 749. Additionally, Daltrey Turner, LICSW, met with Jane's mother and explained she would serve as the family liaison during Jane's treatment at Riggs. AR at 549-50.

         2. HPHC's Initial Approval of Residential Treatment

         UBH approved coverage for Jane's admission to Riggs. AR at 226. UBH noted on January 18, relying on information from Dr. Flynn, that Jane had four psychotic episodes and three inpatient admissions in the previous year, poor responses to medication and no current psychosis or suicidal intent. Id. Jane requested coverage for twenty-eight days at the time of admission; UBH approved coverage for seven days. AR at 225-26.

         3. Jane's Clinical Treatment: January 17, 2013 ...

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