L.D. v. UnitedHealthcare Ins.

684 F.Supp.3d 1177

L.D., individually and on behalf of K.D., a minor, Plaintiff, v. UNITEDHEALTHCARE INSURANCE, United Behavioral Health, andInsperity Group Health Plan, Defendants.

Case No. 1:21-cv-00121-RJS-DBP

United States District Court, D. Utah

Signed July 28, 2023

Brian S. King, Brent J. Newton, Samuel Martin Hall, Brian S. King PC, Salt Lake City, UT, for Plaintiff.

Christopher J. Martinez, Ashley Walker, Dorsey & Whitney LLP, Salt Lake City, UT, for Defendants.

MEMORANDUM DECISION AND ORDER

ROBERT J. SHELBY, United States Chief District Judge

Defendants covered minor K.D.'s¹ stay in a residential treatment center (RTC) for a little over two months. After Defendants determined residential treatment was no longer medically necessary, they stopped covering the treatment, and K.D.'s mother sued Defendants individually and on K.D.'s behalf. The parties filed competing Motions for Summary Judgment, and the court heard argument on the Motions. For the reasons explained below, both Motions are GRANTED in part and DENIED in part.

BACKGROUND²

The Insperity Group Health Plan (the Plan) is a fully insured welfare benefits plan established for employees of Insperity Holdings, Inc.³ Insperity Holdings administers the Plan along with UnitedHealthcare Insurance (United), which is the Plan's claims fiduciary.⁴ At all relevant times, K.D.'s mother, L.D., was a participant in and K.D. was a beneficiary of the Plan.⁵ The court will first explain the Plan, then K.D.'s relevant medical history, and finally Plaintiffs' administrative appeals.

I. The Plan

The Plan pays for treatment that is a Covered Health Care Service, medically necessary, and not excluded.⁶ The Plan defines "medically necessary" as follows:

[H]ealth care services provided for the purpose of preventing, evaluating, diagnosing or treating a Sickness, Injury, Mental Illness, substance-related and addictive disorders, condition, disease or its symptoms, that are all of the following as determined by us or our designee.

• In accordance with Generally Accepted Standards of Medical Practice.

• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your Sickness, Injury, Mental Illness, substance-related and addictive disorders, disease or its symptoms.

• Not mainly for your convenience or that of your doctor or other health care provider.

• Not more costly than an alternative drug, service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your Sickness, Injury, disease or symptoms.⁷

The Plan defines "Generally Accepted Standards of Medical Practice" as standards "based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes."⁸

United used the Optum Level of Care Guidelines (LOC Guidelines) to review Plaintiffs' request for RTC benefits.⁹ Under the LOC Guidelines, admission to an RTC is appropriate when the following conditions are met:

• The member's current condition cannot be safely, efficiently, and effectively assessed and/or treated in a less intensive level of care.

? Failure of treatment in a less intensive level of care is not a prerequisite for authorizing coverage.

? The member's overall condition includes consideration of the acute and chronic symptoms and diagnoses in the member's history and presentation including co-occurring behavioral health or medical conditions, informed by the information collected by the provider following evaluation and treatment planning described in the Common Best Practices. For children and adolescent members, evaluation of the appropriate treatment and level of care for a member's condition must account for the unique needs of children and adolescents, including age, developmental stage, and the pace at which they respond to treatment, as well as family, caregiver, school and other support systems.

AND

• The member's condition can be safely, efficiently, and effectively assessed and/or treated in the proposed level of care. Assessment and/or treatment of the member's condition require the intensity and scope of services provided in the proposed level of care.

AND

• Co-occurring behavioral health and medical conditions can be safely and effectively managed in the proposed level of care.

• Services are medical necessary¹⁰ defined as:

? Consistent with generally accepted standards of clinical practice;

? Consistent with services backed by credible research soundly demonstrating that the service(s) will have a measurable and beneficial health outcome, and are therefore not considered experimental;

? Consistent with Optum's best practice guidelines;

? Clinically appropriate for the member's behavioral health conditions based on generally accepted standards of clinical practice and benchmarks.

AND

• For all levels of care, services must be for the purpose of diagnostic study or reasonably be expected to improve the patient's condition. The treatment must, at a minimum, be designed to reduce or control the patient's psychiatric symptoms so as to prevent relapse or hospitalization, and improve or maintain the patient's level of functioning.

. . . .

AND

• Safe, efficient, effective assessment and/or treatment of the member's condition requires the structure of a 24-hour/seven days per week treatment setting. Examples include the following:

? Impairment of behavior or cognition that interferes with activities of daily living to the extent that the welfare of the member or others is endangered.

? Psychosocial and environmental problems that are likely to threaten the member's safety or undermine engagement in a less intensive level of care without the intensity of services offered in this level of care.¹¹

The LOC Guidelines also set the criteria for a continued stay in an RTC:

• The admission criteria continue to be met and active treatment is being provided. For treatment to be considered "active," service(s) must be as follows:

? Supervised and evaluated by the admitting provider;

? Provided under an individualized treatment plan consistent with Common Clinical Best Practices;

? Reasonably expected to improve the member's mental health/substance use disorder condition(s).

AND

• The factors leading to admission have been identified and are integrated into the treatment and discharge plans.

AND

• Clinical best practices are being provided with sufficient intensity to address the member's treatment needs . . . .

AND

• The member's family and other natural resources are engaged to participate in the member's treatment as clinically indicated and feasible.

AND

• Treatment is not primarily for the purpose of providing custodial care. Services are custodial when they are any of the following:

? Non-health-related services, such as assistance in activities of daily living (examples include feeding, dressing, bathing, transferring, and ambulating);

? Health-related services provided for the primary purpose of meeting the personal needs of the member;

? Services that do not require continued administration by trained medical personnel in order to be delivered safely and effectively.¹²

Relevant to Plaintiffs' Parity Act claim, the Plan also covers medical/surgical treatment at skilled nursing facilities and inpatient rehabilitation facilities, if medically necessary.¹³ The parties agree these facilities are analogous to RTCs.¹⁴ At all relevant times, Defendants used the Milliman Care Guidelines (MCGs) to evaluate the medical necessity of treatment at skilled nursing facilities and inpatient rehabilitation facilities.¹⁵

II. Relevant Medical History¹⁶

A. K.D.'s Childhood

K.D.'s parents adopted her when she was born.¹⁷ For several years, K.D. was "bright and cheerful," but she started to have "attachment anxiety" when she was four.¹⁸ For example, K.D. struggled to attend school and often had meltdowns when she got home.¹⁹ When K.D. continued to struggle despite help from her teacher and school counselor, her parents enrolled her in counseling.²⁰

K.D. was a "model student" at school, but it was difficult for her to socialize and develop meaningful relationships.²¹ She continued to have meltdowns at home, and she was given multiple possible diagnoses, including general anxiety disorder, oppositional defiant disorder, and disruptive mood dysregulation disorder.²² As K.D. got older, she became more aggressive, particularly towards her parents.²³ K.D.'s family tried to address this behavior, but nothing seemed to help.²⁴ Her parents also met regularly with her school because she said she was being bullied.²⁵ Moreover, K.D. often said she would be "better off dead," sometimes screaming it when she had a meltdown.²⁶

The summer before K.D. started fifth grade, she started having pseudo-seizures, and a doctor recommended she see a psychiatrist.²⁷ K.D. visited a psychiatrist, a neurologist, and a nurse practitioner, and she started taking prescription drugs.²⁸

For the next several years, K.D. continued to struggle. Although she was taking prescription drugs, attending counseling, and had received multiple diagnoses, her parents saw no improvement.²⁹ When she was in sixth grade, K.D. "tried to beat [her] mom up and did a good job."³⁰ The next day, she told her teacher that her mother hit her, and social services opened an investigation, which they closed after speaking with the family.³¹ After this incident, K.D. began to isolate more and struggled with bullying, particularly online.³² One evening, she threated to kill herself, and her parents called a crisis hotline, which sent a team to help K.D. and her family.³³ On another occasion, K.D.'s parents called the police after K.D. threatened to hurt her family and commit suicide.³⁴

When K.D. started middle school, the...