United States District Court, D. Massachusetts
MEMORANDUM AND ORDER ON THE PARTIES'
CROSS-MOTIONS FOR SUMMARY JUDGMENT
Dennis Saylor, IV United States District Judge.
an action under the Employee Retirement Income Security Act
of 1974 (“ERISA”), 29 U.S.C. §§ 1001
Addie Fisher contends that defendant Harvard Pilgrim Health
Care of New England, Inc. (“HPHC”) failed to pay
her medical benefits that she was owed under her health plan.
Specifically, she challenges HPHC's decision to stop
paying for residential treatment for her eating disorder on
the ground that it was not medically necessary.
parties have filed cross-motions for summary
judgment. For the following reasons, HPHC's
motion will be granted and Fisher's motion will be
following facts are undisputed unless noted otherwise.
times relevant to this case, Addie Fisher was a covered
beneficiary under an employer-provided HMO health-care plan
issued by HPHC. (Def. SMF ¶ 1). HPHC contracted with
United Behavioral Health (“UBH”) to make initial
coverage determinations for its beneficiaries. (Id.
¶ 2; Partial Record for Judicial Review 0052). UBH
operated under the brand Optum. (Record 0126).
plan covered only medical services that were deemed to be
“Medically Necessary.” (Record 0023). The plan
defined “Medically Necessary” services as
[t]hose medical services which are provided to a Member for
the purpose of preventing, stabilizing, diagnosing or
treating an illness, injury or disease, or the symptoms
thereof, in a manner that is (a) consistent with generally
accepted standards of medical practice, (b) clinically
appropriate in terms of type, frequency, extent, location of
service and duration, (c) demonstrated through scientific
evidence to be effective in improving health outcomes, (d)
representative of best practices in the medical profession,
and (e) not primarily for the convenience of the enrollee or
physician or other health care provider.
plan provided that HPHC (and UBH) would “use clinical
review criteria” to “evaluate whether certain
services or procedures [were] Medically Necessary.”
2015, UBH issued a “Level of Care Guidelines”
that listed “Common Criteria and Clinical Best
Practices for All Levels of Care.” (Record 0319). The
first section provided nine “Admission Criteria,
” two of which, criteria 1.4 and 1.8, are particularly
relevant. Criterion 1.4 provided:
1.4 The member's current condition cannot be safely,
efficiently, and effectively assessed and/or treated in a
less intensive level of care due to acute changes in the
member's signs and symptoms and/or psychosocial and
environmental factors (i.e., the “why now”
factors leading to admission).
1.4.1 Failure of treatment in a less intensive level of care
is not a prerequisite for authorizing coverage.
(Record 0319). Criterion 1.8 provided:
1.8 There is a reasonable expectation that services will
improve the member's presenting problems within a
reasonable period of time.
1.8.1. Improvement of member's condition is indicated by
the reduction or control of the acute signs and symptoms that
necessitated treatment in a level of care.
1.8.2. Improvement in this context is measured by weighing
the effectiveness of treatment against evidence that the
member's signs and symptoms will deteriorate if treatment
in the current level of care ends. Improvement must also be
understood within the broader framework of the member's
recovery, resiliency and wellbeing.
first received treatment for bulimia nervosa in December
2014. On December 2, 2014, she was admitted to Walden
Behavioral Care, a private psychiatric hospital in Waltham,
Massachusetts. (Def. SMF ¶ 7). On December 29, she
started Walden's “partial hospitalization
program.” (Id.). On January 14, 2015, after
being discharged from the partial hospitalization program,
she was approved for an intensive outpatient program, but
never actually received any outpatient treatment.
26, 2015, Fisher's mother called UBH and sought
permission for her to attend the Oliver Pyatt Center, an
eating-disorder treatment center in Miami, Florida.
(Id. ¶ 8). Later that day, Fisher was admitted
to a hospital in New Hampshire after she expressed suicidal
thoughts. (Id.). She was discharged from the New
Hampshire hospital on May 28 and soon thereafter began
receiving treatment at the Oliver Pyatt Center in Florida.
(Id.). Although Oliver Pyatt was out of UBH's
network, Fisher and UBH reached a “single case
agreement” to cover her residential treatment, as there
were no eating-disorder treatment centers “in
geo-access” of Fisher's home in New Hampshire.
(Id. ¶ 8-9, Record 0098).
residential treatment at Oliver Pyatt ended on July 31, 2015.
(Id. ¶ 11). It appears that she began receiving
treatment through Oliver Pyatt's partial hospitalization
program on August 1. (Record 0126). On August 3, an Oliver
Pyatt representative called a UBH “Care Advocate”
named Stefanie Adzema and requested that UBH approve coverage
for Fisher's treatment in its partial hospitalization
program. (Id. ¶ 13). Adzema conducted a
“Facility Based Review” and concluded that Fisher
did not appear to “meet [the] medical necessity
guidelines” for a partial hospitalization program.
(Record 0174). Accordingly, she referred Fisher's case to
a UBH Associate Medical Director, Dr. Melinda Privette, for a
“peer-to-peer review.” (Id.).
August 4, 2015, Dr. Privette conducted a “very
difficult” peer-to-peer review that included a morning
telephone interview with Fisher's treating physician,
psychologist, and social worker at Oliver Pyatt. (Def. SMF
¶ 16, Record 0176). According to Dr. Privette's
notes of the call, the Oliver Pyatt representatives
“stated that [Fisher] needed to stay” in the
partial hospitalization program because (1) she had
“just reached the point of stability” and still
needed to “work on self-plating meals and going on more
passes;” (2) she needed “more individual therapy
to work on her anxiety about eating” and
“want[ed] to connect with her birth parents;” and
(3) neither Fisher nor her parents would be able to drive her
to an outpatient program. (Record 0179).
Privette disagreed with that assessment. In her note of the
review, apparently submitted at 12:40 p.m. on August 4, she
concluded that Fisher could be safely and effectively treated
with intensive outpatient treatment and thus that the
requested partial hospitalization program at Oliver Pyatt did
“not meet” the “level of care guideline
required to be followed” under the plan. (Record
same day, Dr. Privette sent Fisher a letter informing her
that “the request by [Oliver Pyatt] for authorization
for Mental Health Partial Hospitalization Treatment beginning
on 08/01/2015 has been denied by Optum.” (Record 0126).
The letter continued:
Under the terms of our agreement with Harvard Pilgrim,
services must be medically necessary and otherwise covered
under the plan. It is Optum's determination that services