K.S. v. Cigna Health & Life Ins. Co.

1

K.S., and Z.S., Plaintiffs, v. CIGNA HEALTH AND LIFE INSURANCE COMPANY, and the ACCENTURE LLP BENEFITS PLAN, Defendants.

No. 1:22-cv-00004-TC-DBP

United States District Court, D. Utah, Northern Division

July 8, 2024

Dustin B. Pead, Magistrate Judge

ORDER AND MEMORANDUM DECISION ON MOTIONS FOR SUMMARY JUDGMENT

TENA CAMPBELL United States District Judge

Plaintiff K.S., the mother of Plaintiff Z.S., was a participant in Defendant the Accenture LLP Benefits Plan (the Plan) through her employer Accenture LLP. As a dependent of K.S., Z.S. was a beneficiary of the Plan. K.S. sought coverage under the Plan for the residential mental health treatment that Z.S received from February 5, 2019, to March 8, 2020, at a Utah facility called “Elevations.” Defendant Cigna Health and Life Insurance Company (Cigna), the Plan's designated claims administrator, denied coverage for Z.S.'s treatment under the Plan. K.S. twice appealed Cigna's decision to deny coverage, and Cigna upheld its determination at both levels of appeal. The Plaintiffs then sued the Defendants in this court, asserting two claims: 1) a claim for the recovery of benefits under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. § 1132(a)(1)(B) (the denial of benefits claim), and 2) a claim for a violation of the Mental Health Parity and Addiction Equity Act (the Parity Act), 29 U.S.C. § 1132(a)(3). All parties have moved for summary judgment on the denial of benefits claim. (See Pls.' Mot. for Summ. J ECF No. 40; Cigna's Mot. for Summ. J., ECF No. 44; Plan Mot. for Summ. J., ECF No. 45.^[1])

BACKGROUND

I Z.S.'s Medical History Before Elevations

Z.S. has struggled with mental health issues for most of his childhood and adolescence. Born in 2003 and assigned female at birth, Z.S. came out to his parents as a transgender male in middle school. (Administrative Record (AR)^[2] at 2671-72.) His struggles with gender dysphoria, depression, anxiety, and other mental health issues led him to engage in self-harming behaviors throughout adolescence, including cutting and suicidal ideation. (Id. at 3922.) Z.S. attempted suicide three times. (Id. at 3935.)

Because of his mental health struggles, Z.S. saw many therapists, some of whom expressed concern over Z.S.'s suicidal ideation and cutting, and recommended to Z.S.'s parents that Z.S. be hospitalized. (Id. at 2672-73, 2822.) After being hospitalized three times, enrolling in a partial hospitalization program (PHP), and completing multiple intensive outpatient programs (IOPs), Z.S.'s psychiatrist recommended that Z.S.'s parents begin looking into residential treatment for Z.S. (Id. at 2673-74, 2725-35, 2747-55, 2808, 3923.) In May 2018, Z.S. was admitted to Evolve Treatment Center and stayed for 30 days. (Id. at 2808.)

When Z.S. was discharged from Evolve, Evolve's clinical staff suggested that Z.S.'s parents consider long-term residential treatment for Z.S. or at least a placement in another IOP. (Id. at 2674.) Z.S.'s parents decided to enroll him in another IOP at Sage Wellness, which he successfully completed. (Id. at 2756-78, 2808.) But a few weeks later, Z.S. admitted to his parents that he was cutting again and having suicidal thoughts. (Id. at 2674.) Z.S. was admitted to the hospital for a fourth time. (Id. at 2674, 2808.) Z.S.'s parents then found the Polaris Team Center (Polaris), a short-term residential treatment program where Z.S. enrolled and had some success between December 2018 and early February 2019. (Id. at 2806, 2808, 3922-23.) Even so, Polaris' clinical staff recommended that Z.S.'s parents consider long-term residential mental health treatment for Z.S. (Id. at 2675.) The record shows that Z.S. engaged in self-harming behavior about two weeks before he got to Elevations (id. at 3923, 4795), which means that he self-harmed while at Polaris.

II. Z.S.'s Treatment at Elevations

Z.S.'s parents enrolled Z.S. into long-term residential treatment at Elevations on February 5, 2019. (Id. at 4156.) Elevations staff completed a psychiatric admission evaluation for Z.S. On February 6, 2019. (Id. at 3922.) Z.S.'s “Admission Criteria” included: “history of suicide attempts; chronic history of suicidal ideation; history of chronic self-mutilation; .. failed inpatient, outpatient, short term residential, IOP, and PHP treatment; inadequate community support systems/resources including inability to be contained in the home setting due to extreme self-harm attempt history[.]” (Id.) Z.S.'s “History of Present Illness” read as follows:

[Z.S.] presents to Elevations Residential Treatment Center as a 15-year-old student upon transfer from short-term residential experiential program ‘Polaris'. [Z.S.] has been predominantly in high acuity settings over the preceding year, which includes 5 inpatient hospitalizations over a preceding 15 months, multiple partial hospitalization placements after inpatient hospitalizations, and two shortterm residential programs. [Z.S.] was placed in these settings to combat severely chronic suicidal and self-harm ideation, with repetitive attempts and failure to find significant success despite the amount of intervention. Numerous medication trials have occurred, with limited efficacy to date.... [Z.S.] was noted to have significant anxiety with periodic anger issues as a youth, which gradually developed into severe depression since late elementary school. Gender dysphoria became a more overt and understood part of his formulation around the age of 11 to 12 .. Despite interventions, he has continued to have body and gender dysphoria amplifying depressive and anxious symptoms. [Z.S.] has struggled with body image, and has engaged in periodic restriction, but more commonplace binge eating. ADHD related symptoms have been diagnosed over recent years[.]

(Id. (emphasis added).) Based on the evaluation, Z.S.'s diagnosis included major depressive disorder, generalized anxiety disorder, social anxiety disorder, panic disorder, gender dysphoria, and non-suicidal self-harm. (Id. at 3925.) Staff also made a preliminary treatment plan for Z.S., which directed that he “[would] be placed in weekly individual and family therapy, with daily group therapy[,]” continue taking medications, and that his “[e]stimated length of stay [was] ... 4 to 12 months . [and his] [anticipated discharge disposition [would be an eventual] step-down to lower acuity setting vs. home with wrap around services.” (Id.)

Z.S.'s risk level for self-harm and suicidal behaviors varied while at Elevations. Clinical staff deemed Z.S. to be a “Mild Risk” for self-harm and suicidal behaviors upon entering Elevations because he did not have suicidal thoughts or a suicidal plan. (Id. at 3935.) But Z.S. stated on February 6, 2019 (a day after admission to Elevations), that he had “suicidal and selfharm urges . upon admission.” (Id. at 3923 (emphasis added).) On February 7, 2019, Z.S.'s Primary Therapist Andrea Hanson deemed him to be a “Moderate Risk,” noting “[r]egular thoughts” and a “[v]ague plan.” (Id. at 3920.) At various times in March, April, and May 2019, Ms. Hanson noted that “[Z.S.] [was] at high risk for self-harm and suicidal behavior outside of a restricted environment[.]” (Id. at 3759, 3764; see also id. at 3466, 3476, 3540, 3664, 3729, 3734.) On May 6, 2019, “[Z.S.'s] lack of insight and low ability to regulate his mood [made] him likely to engage in self-harm and suicidality outside of a residential environment.” (Id. at 3717 (emphasis added).) At various points throughout his stay, Z.S. also reported having no thoughts of hurting himself to Ms. Hanson. (Id. at 2924, 3515.)

III. The Plan

The Plan provides coverage for behavioral health and medical/surgical services rendered by in-network and out-of-network providers, so long as the care received is “medically necessary.”^[3]This means that the Plan gives coverage for medically necessary services for mental health and substance use disorders, including inpatient and outpatient mental health services. (Id. at 4686-87, 4746-47.) The Plan excludes coverage for “care, treatment, or surgery” not medically necessary for Plan participants and any dependents. (Id. at 4755, 4695.) The Plan defines “medically necessary” as follows:

Health care services, supplies and medications provided for the purpose of preventing, evaluating, diagnosing or treating a Sickness, Injury, condition, disease or its symptoms, that are all of the following as determined by a Medical Director or Review Organization:

• required to diagnose or treat an illness, Injury, disease or its symptoms;

• in accordance with generally accepted standards of medical practice;

• clinically appropriate in terms of type, frequency, extent, site and duration;

• not primarily for the convenience of the patient, Physician or other health care provider;

• not more costly than an alternative service(s), medication(s), or supply(ies) that is at least as likely to produce equivalent, therapeutic or diagnostic results with the same safety profile as to the prevention, evaluation, diagnosis or treatment of your Sickness, Injury, condition, disease or its symptoms; and

• rendered in the least intensive setting that is appropriate for the delivery of services, supplies or medications. Where applicable, the Medical Director or Review Organization may compare the cost-effectiveness of alternative services, supplies, medications or settings when determining least intensive setting.

(Id. at 4709, 4769.) The Plan also defines “Mental Health Residential Treatment Services” as services provided “for the evaluation and treatment of the psychological and social functional disturbances that are results of subacute Mental Health conditions.” (Id. at 4686.) The Plan defines “Mental Health Residential Treatment Center” as:

[An]

...