AeroCare Med. Transp. Sys. v. Tractor Supply Co.

AEROCARE MEDICAL TRANSPORT SYSTEM, INC. and CAROL HEISZ, Plaintiffs, v. TRACTOR SUPPLY COMPANY, Defendant.

No. 3:20-cv-00179

United States District Court, M.D. Tennessee, Nashville Division

August 4, 2021

MEMORANDUM

ALETA A. TRAUGER United States District Judge

Plaintiff Carol Heisz^[1] brings this case under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C § 1001 et seq., seeking to recover expenses incurred in connection with air ambulance transportation services performed by AeroCare Medical Transport System, Inc. (AeroCare) on January 27, 2017, to fly her from Freeman Medical Center in Joplin, Missouri to Select Specialty Hospital in Madison, Wisconsin. (Complaint, Doc. No. 1.) Now before the court are cross Motions for Judgment on the Administrative Record filed by both Heisz (Doc. No. 55) and defendant Tractor Supply Company (TSC) (Doc. No. 56). For the reasons set forth herein, the court will grant the defendant's motion and deny the plaintiff's.

I. REVIEW OF THE RECORD^[2]

A. The Accident, Initial Treatment, and Transport

On December 30, 2016, Carol Heisz and her husband, Lee Heisz, who lived in Madison, Wisconsin, were in an automobile accident in Joplin, Missouri. (AR 144.) Lee Heisz was killed in the accident. (AR 144.) Carol Heisz suffered numerous serious injuries, including a spinal injury that caused permanent paralysis from the chest down. (AR 144, 35.) Carol Heisz (hereafter, “Heisz”) was transported to the Freeman Medical Center in Joplin, Missouri for treatment. (AR 61.)

At the time of the accident, Heisz's husband was employed by defendant TSC, and both he and Heisz were covered by TSC's medical insurance plan (the Plan). The Plan was, at all relevant times, a self-funded health plan maintained by TSC and governed by ERISA. (AR 587.) TSC was and is the named plan administrator. (AR 5340.) BlueCross BlueShield of Tennessee, Inc. (BCBST) served as the Plan's third-party claims administrator.^[3] (AR 478, 507.) BCBST contracted with BlueCross BlueShield of South Carolina (BCBSSC) (collectively with BCBST, BCBS) to serve as the primary provider of claims processing, customer service, and medical management. (AR 507.)

On the date of Heisz's admission to Freeman Medical Center, consulting physician Dr. Alan Buchele noted that she would be admitted for more than two days, that her “[d]isposition at this time is uncertain, ” and that she would “likely” be discharged to a “rehabilitation facility closer to home.” (AR 64.) The treatment notes from a “routine” psychiatric consultation on January 1, 2017, associated with Heisz's having suffered the death of her husband and paralysis in the accident, indicated that she was started on antidepressant medication, that she would “benefit from continued therapy, ” and that family members were present who would “assist with locating psychiatric and therapeutic resources in Wisconsin [where] the patient plans to return after discharge from hospital.” (AR 69; see also AR 75 (“Discussed follow up plans with patient and family. Pt plans to return to Wisconsin.”).)

On January 2, 2017, Heisz underwent fusion surgery on her spine, which was accompanied by numerous complications, including post-operative respiratory failure and acute blood loss secondary to a hemothorax. (AR (AR 76, 82, 84, 102.) As of January 4, 2017, she was improving, and the Freeman Medical Center anticipated transferring her to rehabilitation the following week. (AR 102.) However, her treatment notes indicate that she had a pulmonary angiogram and placement of an IVC filter on January 8, a bronchoscopy and mucous plug removal on January 13, and tracheostomy on January 16, 2017. (See AR 179, 146, 138.) As of that date, she was noted to have tolerated the procedure well and was “more stable than last week.” (AR 138.) The plan was to discharge her to “Wisconsin rehab.” (Id.)

Her discharge summary from Freeman Medical Center, dated January 24, 2017, briefly relates her course of treatment and complications over the preceding weeks and states that she had been “stable over this last week and has been moved out to the floor” from the ICU. (AR 162.) Without any further explanation, the summary notes: “She will be transferring by air due to her multiple issues and complex hospital stay for her safety. She will need to go to select^[4] for rehab and respiratory [treatment].” (Id.) The only other reference to her out-of-state residency appears under the heading “Discharge Diagnosis”: “Social services is starting the discharge process she is from out of town.” (AR 164.) Her “Condition on Discharge” was “Stable”; her “Discharge Disposition” was “Rehab Facility.” (AR 166.) The summary concluded with “Special Physician Instructions” relating to activity, wound care, follow-up appointments to check the alignment and fusion of her spine, tracheostomy management, feeding tube management, and medications. (AR 166-67.) The patient was observed to be stable and to state that she was “feeling well and want[ed] to go home.” (AR 167.)

The record does not suggest that Heisz's treating providers at Freeman Medical Center had any involvement in the selection of the rehabilitation facility to which Heisz would be admitted after discharge from Freeman Medical Center. Nor does the record reflect how or when exactly Heisz selected Select Specialty Hospital (“Select”) in Madison, Wisconsin as the rehabilitation facility to which she desired admittance, but it apparently happened fairly early in the process. On January 6, 2017, Select^[5] sought prior authorization from BCBS to provide rehabilitation services to Heisz following her discharge from Freeman Medical Center. (AR 31, 32.) Preauthorization was apparently granted, as this appeal does not concern coverage for Heisz's treatment at Select. In addition, Select also inquired about preauthorization for Heisz's transport to its facility. Case manager notes from BCBS indicate that “AFOWLER, RN” had “received a call from Sandy/LTAC^[6] who wanted to send in clinicals. Informed Sandy that air transport will not be covered from Missouri to Wisconsin per the member's Group. She will let her facility know this. Will leave LTAC case open until I hear back from facility.” (AR 30.) A note from the following day indicates that “Sandy/LTAC” had left a voicemail stating that she was “waiting to hear from auto insurance about payor for air transport from Missouri to Wisconsin.” (Id.) On January 24, 2017, A. Fowler, RN entered a note stating: “PC to Sandy/LTAC requesting that she have transport company send in clinicals for transport authorization. Sandy stated that they will not send in because [Member's] family is to pay out of pocket. Informed her that denial cannot be sent to [Member] or provider if no request is sent in.” (Id.)

The Administrative Record does not reflect that any additional effort was made, by AeroCare or Heisz's family, to obtain preauthorization for the air transport. Because no formal request for preauthorization was made, BCBS had no call to issue a pre-transport denial letter- or, for that matter, an approval. In any event, no such denial letter is in the record.

The record includes a “Physician/Provider Statement for Medical Necessity and Reasonableness for Air Medical Transport.” (AR 148.) This form is not signed, and it is unclear who prepared it. It has a fax-stamp date on it of January 23, 2017 and was emailed to Ann Cashner, who is not identified in the record, by Rebecca Werth, who is identified elsewhere in the record as AeroCare's Vice President of Operations. (AR 495.) The form identifies the patient as Carol Heisz, the Requesting Facility and Requesting Physician as Freeman Hospital West and Brian Curtis, M.D., respectively, and the Accepting Facility as Select Specialty Hospital in Madison, Wisconsin. (AR 148.) Someone^[7] wrote on the form, in support of the medical necessity of air transport, “patient's condition is too critical to allow for longer transport time by ground” due to “respiratory compromise, pulmonary embolism, cervical fractures.” (Id.) In addition, the box is checked next to the line on the form stating “Patient requires specialty level of care that cannot be rendered at current facility, ” and a handwritten note explains: “patient requires specialty LTAC near residence/family.” (Id.)

Heisz was transported by AeroCare from Joplin, Missouri to Madison, Wisconsin on January 26, 2017. (AR 214-21.) Under “Payment Information” on documentation of the transport, the notes reflect, in answer to the inquiry “Why Transport Called, ” “Medically Necessary Transport (Not Nearest Facility).” (AR 214.) There is no dispute that Heisz, at that time, remained in serious condition and that she received critical care and monitoring during the transport. (AR 216-21.)

The record includes a General Release and Consent dated January 26, 2017 and signed by Laura Wentz, Heisz's sister, on behalf of Heisz. According to this form, Wentz, “acting for and on behalf of the patient and accompanying passengers, ” consented to critical care transport by AeroCare, released AeroCare and its personnel from liability, agreed to “cooperate fully with [AeroCare] in their efforts to obtain payment for this transport, ” and also acknowledged personal liability for the charges associated with the transport. (AR 633.)^[8]

B. Handling of the Claim

In early March 2017-approximately six weeks after it transported Heisz and two months after BCBS first discussed air transportation with someone at Select-AeroCare submitted a claim for payment of services to BCBS, seeking payment in the amount of $140, 750. (AR 211.) On March 15, 2017, BCBS issued an Explanation of Benefits (EOB) to Heisz, stating that the entire amount of the claim was “not covered” and,...