D. v. United Healthcare Insurance Company

Filing 27

ORDER re Statement of Decision Pursuant to FED.R.CIV.P. 52. Judgment is awarded in favor of United Behavioral Health, and against Plaintiff. The court will prepare a separate judgment. Signed by Judge Jeffrey T. Miller on 8/1/2016.(rlu)

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UNITED STATES DISTRICT COURT

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SOUTHERN DISTRICT OF CALIFORNIA

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KIMBERLEY D.,

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v.
UNITED HEALTHCARE
INSURANCE COMPANY,

CASE NO. 15cv1012 JM(BLM)
Plaintiff,

STATEMENT OF DECISION
PURSUANT TO FED.R.CIV.P. 52

Defendant.

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INTRODUCTION
On May 5, 2015, Plaintiff Kimberley D. commenced this Employee Retirement
Income Security Act (“ERISA”) action seeking damages for Defendant United
Healthcare Insurance Company’s (“UHIC”) alleged breach of the LifeLock, Inc.
Welfare Benefit Plan (“Plan”). Plaintiff broadly alleges that she has a 30-year history
of mental illness consisting of major depressive disorder, generalized anxiety disorder,
borderline personality disorder, and an eating disorder. When Plaintiff, a San Diego
resident, self-referred to an Arizona residential treatment center, Sierra Tucson, for
treatment of escalating depression and worsening eating disorder associated with life
stressors, UHIC, through the mental health benefits administrator, United Behavioral
Health (“UBH”), determined that inpatient treatment was not medically necessary as
that term is defined in the Plan. Plaintiff alleges that the denial of the medically
necessary treatment violated the Plan.

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1

The parties agree that the de novo standard of review applies to Plaintiff’s

2 claims. The parties also agree to the contours of the evidentiary record submitted by
3 the parties. Based upon the parties’ submissions, the issue before the court is simply
4 whether the inpatient residential treatment received by Plaintiff was medically
5 necessary under the circumstances of this case and, therefore, a covered benefit under
6 the Plan. Having carefully considered the matters presented, the court record,
7 appropriate legal authorities, and the arguments of counsel, the court concludes that
8 Plaintiff fails to show that UHIC breached the Plan.
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FINDINGS OF FACT

10 Plaintiff’s Medical History
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Plaintiff is a 51-year old woman with a history of mental illness and eating

12 disorders. On April 22, 2013, Plaintiff was admitted to the Eating Disorder Center of
13 San Diego (“EDCSD”) and diagnosed with bulimia nervosa, and secondary diagnoses
14 of major depressive disorder, recurrent, severe without psychotic features and
15 posttraumatic stress disorder.

(UBH 1441). The EDCSD report indicates the

16 following symptoms: “binge eating daily; restricts all day, binges at night, gained 35
17 pounds since last October; using enemas and laxatives 2-3 times week; panic attacks;
18 obsessing about food in house and hypervigilant.” (UBH 1442). The report indicated
19 that Plaintiff was not at imminent risk to herself or others. Id.
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From April through August 2013, UBH authorized Plaintiff to receive 33

21 intensive outpatient sessions at out-of-network EDCSD to focus on her eating and
22 related disorders. After discharge, Plaintiff underwent an additional 30 outpatient
23 treatment sessions with focus on her eating and related disorders. Plaintiff received
24 these treatments periodically through May 2014.
25 Admission to Sierra Tucson
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On May 6, 2014, Plaintiff’s husband called UBH and stated that a therapist

27 suggested that Plaintiff receive inpatient treatment at Sierra Tucson. The cryptic notes
28 from the telephone conversation indicate that the UBH representative informed
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1 Plaintiff’s husband that inpatient residential treatment was available upon showing
2 medical necessity. The term medical necessity was explained to Plaintiff’s husband.
3 On May 8, 2014, Sierra Tucson called UBH to inquire about coverage and was
4 informed that authorization was required for inpatient treatment.
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On May 9, 2014, UBH called Plaintiff and inquired about her status and whether

6 she needed assistance. The notes indicate that Plaintiff was not in crisis or at risk.
7 Plaintiff reported that she was having difficulty coping with her home life and her
8 eating order symptoms were “very hard to manage.” Plaintiff also stated that her
9 therapist recommended placement in Sierra Tucson, a residential inpatient facility, to
10 treat her symptoms and mood/coping abilities. Plaintiff also informed the UBH
11 representative about an “escalating home situation” involving her son and his
12 girlfriend. The representative also suggested that Plaintiff consider a facility closer to
13 her home in San Diego, California.
14 The Initial Psychiatric Evaluation by Sierra Tucson
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On May 13, 2014, without authorization for residential treatment, Plaintiff

16 admitted to Sierra Tucson for inpatient residential treatment where she received a
17 psychiatric evaluation by Dr. Nia Sipp, a psychiatrist. The evaluation noted: CHIEF
18 COMPLAINT: "...I was looking for treatment for my son's girlfriend and I thought
19 maybe I could go to treatment myself..." (UBH 188). The HISTORY OF PRESENT
20 ILLNESS section of the evaluation identifies that Plaintiff’s eating disorder symptoms
21 have increased with “life stressors.” The “life stressors” consist of her then present
22 living situation. Plaintiff’s son and his girlfriend lived with Plaintiff as did her
23 husband. She identifies that the girlfriend is “deliberately manipulative,” mentally ill,
24 and engages in damaging behavior. Both her son and the girlfriend are heroin addicts
25 and her husband was in treatment for alcohol use disorder. The girlfriend injured
26 herself and then falsely reported to the police that the son had injured her and
27 threatened to also falsely tell the police that the entire family was involved with her
28 injury. The husband moved out of the home to avoid the false allegations and Plaintiff
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1 commenced a legal action against the girlfriend to effectuate her removal from the
2 home. The HISTORY section concludes:
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Patient endorses depressive and anxious symptoms at this time along with
SI (Suicide Ideation). Patient denies psychotic symptoms. She denies
active SI and denies HI (Homicidal Ideation). Patient has no[] plan or
intent to harm herself or harm others.

6 (UBH 0188).
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Under the PSYCHIATRIC SYMPTOMS section, Dr. Sipp set forth the following

8 evaluation:
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Depression: Pt. first experienced depressive symptoms as a child. She did
not like school and often complained of somatic symptoms in an attempt
to “disappear in school...” Pt. has had three severe depressive episodes as
an adult in 2002, 2005 and 2012. She feels her current depressive episode
is the most severe of the episodes. Her current depressive symptoms are
characterized by hyper somnolence, low energy, anhedonia, carbohydrate
cravings, feeling that her legs feel like “ weights,,.” , poor motivation,
poor memory, low mood, feelings of worthlessness and hopelessness,
recurrent wishes that she was someone else, passive and active suicidal
ideation. Pt. has also had periods where she was unable maintain
appropriate hygiene and grooming while depressed. Pt.’s passive and
active SI during her treatment at EDCSD resulted in multiple safety
assessments and welfare checks. Bipolar Spectrum symptoms: Denies.
Under the PSYCHIATRIC HISTORY section, the subheading identified as
Suicide attempts, the evaluation indicates that, in “2002, patient lost 70 lbs and was
severely depressed with increased suicidal ideation. Patient denies that she made a
suicide attempt at that time.” (UBH 189).
Under the MENTAL STATUS EXAM section, Dr. Sipp noted:
This is a well-developed, well-nourished female in no acute distress. Pt,
is tearful during evaluation. She is alert and oriented x 4, Her hygiene and
grooming are intact. Her eye contact is well maintained. There are no
psychomotor abnormalities observed. Her pace of speech, rhythm of
speech and speech pattern are within normal limits. Her mood is anxious.
Her affect is congruent with mood and full range. Her thought process is
circumstantial and tangential. Her thought content is devoid of suicidal
ideation or homicidal ideations. She denies current intent or plan to
commit suicide or harm herself. She denies perceptual disturbances and
there is no evidence of psychosis. Insight and judgment are fair and
improving. Attention and concentration are intact. Cognition is grossly
intact, but was not formally tested.
Dr. Sipp diagnosed Plaintiff with generalized anxiety disorder, major depressive
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1 disorder recurrent severe, panic disorder, and borderline personality disorder. While
2 Plaintiff argues that Sierra Tucson identified that Plaintiff had made an earlier suicide
3 attempt at some unidentified point in time, (Opening Br. at p.5:22),the evaluation states
4 that, at the time of admission, Plaintiff’s “thought content is devoid of suicidal ideation
5 or homicidal ideations. She denies current intent or plan to commit suicide or harm
6 herself.” (UBH 191).
7 Suicide Risk and Suicide Ideation
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The medical records in this case contain references to suicide ideation (passive

9 or active), suicide attempts, suicidality, suicidal thoughts, and suicide risk. Many of
10 these reference seem to be invoked without definition, context, or explanation.
11 Notwithstanding, this court is able to make some observations and findings regarding
12 the general subject of suicide risk:
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(1) At no time prior to her stay at Sierra Tucson, beginning in May 2015,

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is there any evidence Plaintiff ever attempted suicide.

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(2) Although Plaintiff was initially evaluated at a “high” risk suicide level

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(at a 10-12 on a scale of 20), this initial risk level was not supported by

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either Plaintiff’s chief complaint or history.

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presented with depression, worsening eating disorder and life stressors

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based upon her home environment. She denied active SI and was not

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planning to harm herself or others. Significantly, there is no explanation

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from Dr. Sipp as to why Plaintiff is “checked off” as a “high” suicide risk.

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(3) Dr. Sipp, in her initial evaluation, for some unexplained reason noted

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Plaintiff had passive and active SI, notwithstanding her MENTAL

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STATUS EXAM assessment:

Specifically Plaintiff

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Her thought content is devoid of SI or homicidal ideations.

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She denies current intent or plan to commit suicide or harm

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herself.

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(4) In the “Plan” portion of Dr. Sipp’s initial evaluation, there is no
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mention of any issues or concerns related to suicide risk or ideation.

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(5) There is no explanation in the record as to why Plaintiff was initially

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“checked off” as a “high” suicide risk and shortly thereafter “checked off”

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as a “low” risk (0-2 on a scale of 20).

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(6) The observations and findings of Dr. Sipp with respect to Plaintiff’s

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suicide risk level as “high” are unexplained, inconsistent, at odds with

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Plaintiff’s history and presenting complaints, and unsupported by the

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weight of the medical records.

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(7) It was only after UBH’s initial denial of Plaintiff’s appeal of UBH’s

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determination that residential treatment was not medically necessary that

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Sierra Tucson informed UBH that Plaintiff was having suicidal thoughts

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and discussing stockpiling pills.

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(8) Because Plaintiff’s position that her stay at Sierra Tucson was

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medically necessary, due to her risk of suicide as diagnosed by Dr. Sipp,

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it is Plaintiff’s burden to support that position by a preponderance of the

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evidence to prevail, something she fails to do.

17 UBH’s Initial Claim Decision1
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On May 14, 2014, UBH referred the claim file to its Associate Medical Director

19 Jeffrey Uy to determine whether treatment at Sierra Tucson was “medically necessary”
20 under the Plan. Dr. Uy reviewed Plaintiff’s record and other clinical documentation,
21 including the Sierra Tucson evaluation. Dr. Uy scheduled an appointment with Dr.
22 Sipp to discuss Plaintiff’s medical condition and treatment. Dr. Sipp did not call Dr.
23 Uy. Dr. Uy attempted to reach Dr. Sipp on two different occasions but Dr. Sipp never
24 returned the calls.
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Upon review of the medical records, on May 19, 2014, Dr. Uy concluded that

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At oral argument, Plaintiff vehemently contended that the court may only
consider the final decision of UBH to deny benefits in determining whether (and upon
28 what basis) benefits were properly denied. The court finds it is not inappropriate to set
out the entire claim history for relevant content.
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1 Plaintiff did not satisfy the “medically necessary” requirement under the Plan and
2 stated:
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[f]or admission to an Eating Disorders/Mental Health Residential
Treatment Center from 5/13/2014 forward as per review of the clinical
information provided your condition is reported to be essentially stable.
You are not currently experiencing any acute medical complications.
Your current mood symptoms are reported to be moderate in severity and
your behavior has been well-controlled. You are described as cooperative
and appropriate with others, compliant with treatment recommendations,
and there have been no acting-out behaviors to suggest impulse control
problems or risk of harm. It appears that you can maintain stability and
continue to progress in your recovery with ongoing treatment in a less
restrictive care setting; such as Mental Health and Chemical Dependence/
Substance Abuse Outpatient Services.
(UBH 89, 1494). Dr. Uy also explained that Sierra Tucson was an in-network provider
and, therefore, Plaintiff could not be billed for fees beyond her copayment/deductible
unless she signed a written explicit payment arrangement with Sierra Tucson.
The First Appeal
On or about May 19, 2014, Sierra Tucson requested an urgent appeal of the
adverse claim decision. UBH assigned the appeal to Dr. Natasha Sane, a boardcertified psychiatrist. Dr. Sipp conducted the appeal on behalf of Sierra Tucson and
informed Dr. Sane of her opinion that Plaintiff required residential treatment due to the
acuity of her current symptoms, specifically binge eating, depression, conflicts at home,
and prior suicide attempt.2
By letter dated May 21, 2014, Dr. Sane denied the appeal and advised Plaintiff
as follows:
After talking with your doctor, it seems that though you may need help
and support, you do not require the kind of structure, monitoring and
clinical help provided in a mental health residential setting. You are
reported to be medically stable and not at immediate danger to yourself or
others. You may still have conflicts in family relationships, but these
conflicts are not expected to resolve in this setting. You can continue to

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The court notes that Plaintiff cites UBH 302 for the proposition that Plaintiff
27 had earlier made a suicide attempt. This document does not identify any previous
suicide attempt. As noted above, Sierra Tucson’s medical records indicate that, upon
28 admission, while Plaintiff may have had suicidal thoughts, she did not present a danger
to herself or others.
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work on healthy coping strategies and relationships with outpatient mental
health providers, in collaboration with your medical physician and
nutritionist. Long term residential care is not a benefit that is covered by
your insurance plan. Based on our Level of Care Guideline for Mental
Health Residential Level of Care, it is my determination that authorization
can not [sic] be provided from 5/13/14 forward. Care could continue with
outpatient providers.
(UBH 1497-98).
The Second Appeal
On May 22, 2014, Sierra Tucson informed UBH for the first time that Plaintiff
was having suicidal thoughts. Plaintiff stated that “she has multiple medications
stockpiled at home, and plans to go home, get her meds, and check into a hotel and take
everything or drive into something causing accident.” (UBH 1502). On May 21, 2014,
Dr. Sipp noted in her progress notes that Plaintiff “clearly voiced that she will kill
herself if she has to go home. Patient does not have adequate support or structure in
the home to prevent suicide attempt or to provide increased safety. Primary stressors
are within the home.” (UBH 296). During this time, Plaintiff was monitored at Sierra
Tucson to prevent binge eating and her medications were adjusted (Klonopin, Effexor,
Prozac, Lamictal, Wellbutrin, and Metaformi).
UBH referred Plaintiff’s file to reviewing physician Dr. Diana Antonacci, M.D.
for further review. On May 22, 2014, Dr. Antonacci determined that while "[t]he
facility reports that the patient is imminently dangerous to herself due to her mood
symptoms and her suicidal ideation[,]" it was her opinion that
based upon the information provided, this case does not meet medical
necessity criteria for mental health residential level of care. This patient
requires an emergency assessment regarding her suicidal ideation and risk
of harm to self. She may then require a higher level of care, such as
mental health inpatient level of care.3
(Id. at 1517). UBH then referred Plaintiff’s file to Dr. Randall Solomon, M.D., a
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At oral argument, it was established that mental health inpatient care (or the
alternative of acute hospital evaluation) is appropriate when the psychiatrist determines
27 that the patient is unstable or where suicidality is high. Essentially, it is the highest
level of acute care addressing serious risk of suicide. It ranks higher that non-intensive
28 outpatient care, intensive outpatient care, partial hospitalization, and inpatient
residential treatment, in that order.
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1 board-certified psychiatrist. After review of Plaintiff’s file, on May 23, 2014, Dr.
2 Solomon denied the request for impatient residential care noting:
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This case does not meet medical necessity criteria for mental health
residential level of care. This patient requires an emergency assessment
regarding her suicidal ideation and risk of harm to self. She may then
require a higher level of care, such as mental health inpatient level of care.
. . This determination does not mean that you do not require additional
health care, or that you need to be discharged.
(UBH0084; UBH1518). Plaintiff was once again informed that Sierra Tucson could
not bill Plaintiff for any residential treatment beyond the copay and deductible
amounts. Plaintiff did not seek an emergency assessment with an outside provider to
determine the suicide risk, if any (as required by the terms of the Plan).
The Third Appeal
On May 28, 2014, Sierra Tucson requested an expedited appeal. (UBH1519).
UBH referred the matter to Dr. Svetlana Libus, a board-certified psychiatrist, for
further review. Dr. Sipp informed Dr. Libus of Plaintiff’s suicide ideation and failure
to thrive after one year of intensive outpatient therapy for her eating disorders. After
review of the clinical records, Dr. Libus concluded that Plaintiff “required the kind of
structure, monitoring and clinical help provided in a mental health inpatient setting and
not a residential setting.” (UBH 1520. On May 28, 2014, UBH denied the expedited
appeal.
Plaintiff’s Continued Treatment and Discharge
Despite the denial of benefits, Plaintiff remained at Sierra Tucson. On May 28,
2014, the medical records that Plaintiff still had suicidal thoughts. On June 3, 2014,
Plaintiff suffered a fever and vomiting. On June 4, 2014 Plaintiff was sent to the
emergency room for asceptic meningitis, and admitted for three days after which she
returned to Sierra Tucson. On June 27, 2014, Plaintiff discharged from Sierra Tucson.
The Medical Discharge Summary identified four levels of risk for suicide. Plaintiff
was listed in the lowest risk category.
The Post-Service Appeal
On July 18, 2014, Plaintiff, through counsel, filed a final appeal and enclosed
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1 Sierra Tucson’s medical records to substantiate her claims. The records did not include
2 a signed contract whereby Plaintiff agreed to fully compensate Sierra Tucson for its
3 charges. By letter dated August 8, 2014, UBH informed Plaintiff that she had no
4 financial obligation to Sierra Tucson

“beyond any applicable deductible and

5 copayment,” an amount considerable less than the amount Plaintiff paid for treatment
6 ($38,999.89). In light of the fact that Sierra Tucson could not collect more than the
7 copayments under the Plan, the letter also indicated that “it is not the responsibility of
8 [Plaintiff] to appeal [the denial of coverage].” On or about September 15, 2014,
9 Plaintiff’s husband signed a personal guarantee for the total cost of the treatment,
10 apparently on advice of counsel. (UBH 750).
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On October 6, 2014, UBH referred Plaintiff’s file to Dr. Thomas Blocher, M.D.,

12 who is board-certified in psychiatry and addiction medication. Upon review of the
13 records, Dr. Blocher concluded that Plaintiff could have continued her treatment in an
14 intensive outpatient setting. On October 16, 2014, UBH denied the claim. Dr. Blocher
15 noted:
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You are not in a danger to yourself or others. . . The suicidal ideation that
is documented by the MD is in relationship to going home with life
unchanged, not while in treatment. . . . You were not a danger to yourself
or others. Your medications are stable and had been helpful. You were
cooperating with your doctors, and your behavior was under good control.
The doctor did not need to see you frequently. You did not require 24
hour nursing care. The suicidal ideation that is documented by the MD
is in relationship to going home with life unchanged, not while in
treatment. . .

21 (UBH 64).
22 The Plan
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The Plan provides benefits only for health services that are "medically

24 necessary." (UBH 1062). The Plan defines "medically necessary" as:
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health care services provided for the purpose of preventing, evaluating,
diagnosing or treating a Sickness, Injury, Mental Illness, substance use
disorder, 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
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duration, and considered effective for your Sickness, Injury, Mental
Illness, substance use disorder, 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.

6 (UBH 1117).
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"Generally Accepted Standards of Medical Practice" are "standards that are

8 based on credible scientific evidence published in peer-reviewed medical literature
9 generally recognized by the relevant medical community, relying primarily on
10 controlled clinical trials, or, if not available, observational studies from more than one
11 institution that suggest a causal relationship between the service or treatment and health
12 outcomes." (Id.). UHIC "develop[s] and maintain[s] clinical policies that describe the
13 Generally Accepted Standards of Medical Practice scientific evidence, prevailing
14 medical standards and clinical guidelines supporting our determinations regarding
15 specific services." (UBH 1118). "If no credible scientific evidence is available, then
16 standards that are based on Physician specialty society recommendations or
17 professional standards of care may be considered." The Plan imbues UBH with "the
18 right to consult expert opinion in determining whether health care services are
19 Medically Necessary." (UBH 1117).
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"Covered Health Services" under the Plan include the diagnosis and treatment

21 of medically necessary Mental Illnesses, i.e. "those mental health or psychiatric
22 diagnostic categories that are listed in the current Diagnostic and Statistical Manual of
23 the American Psychiatric Association (“APA”), unless those services are specifically
24 excluded under the Policy." (UBH 1062).
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STANDARD OF REVIEW
Under the de novo standard of review, this Court gives no deference to United’s

27 claim decisions. Rather, this Court “simply proceeds to evaluate whether the plan
28 administrator correctly or incorrectly denied benefits without reference to whether the
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1 administrator operated under a conflict of interest.” Abatie v. Alta Health & Life Ins.
2 Co., 458 F.3d 955, 963 (9th Cir. 2006). Because UBH’s final determination was that
3 residential was not medically necessary for Plaintiff, the court’s analysis is limited to
4 that reason. Harlick v. Blue Shield of California, 686 F.3d 699, 719-20 (9th Cir. 2012).
5 Plaintiff has the burden to show that her treatment at Sierra Tucson was medically
6 necessary. See Muniz v. Amec. Constr. Mgmt., Inc., 623 F3d 1290, 1294 (9th Cir.
7 2010).
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DISCUSSION
Plaintiff argues that she satisfied the criteria for the highest level of care under

10 applicable APA guidelines by showing (1) she “needed the structure and monitoring
11 provided in residential treatment to maintain her safety from suicide and binge and
12 restrict behaviors;” (2) she “had co-occurring behavioral health and medical conditions
13 which could be safely managed in residential treatment;” (3) the so-called “why now”
14 factors support her claim: Plaintiff’s “son and his girlfriend were heroin addicts who
15 lived in Kimberley’s home, associated criminal charges against her son and his
16 incarceration, her husband moving out of the home due to the chaotic living situation,
17 and Kimberley’s inability to improve in intensive outpatient treatment while living at
18 home;” and (4) she had an “‘acute impairment of behavior that interfered with her
19 activities of daily living to the extent that her welfare was endangered (i.e. constant
20 urges to binge, 100% of her time thinking about her weight, and restricting for days).”
21 Plaintiff also identified that she had a GAF score of 35-40 (out of a scale of 100),
22 indicating impairment in such areas as family relations, school, poor judgment, and
23 depressed mood. Further, she suffered “environmental problems” at home (i.e. living
24 with her heroin-addicted son and what Plaintiff describes as his mentally ill girlfriend.
25 (Opening Br. at pp. 18:14 - 19:6).4
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The court noted above that the Plan adopted the Generally Accepted Standards
of Medical Practice to determine whether a treatment is medically necessary. Plaintiff
28 argues that she applied UBH’s 2014 Level of Care Guidelines for Residential
Treatment to her condition. However, Plaintiff does not identify how the two
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The court concludes that Plaintiff fails to meet her burden to show that inpatient

2 residential treatment was medically necessary. First, scant evidence supports Plaintiffs
3 claim that residential treatment was required to provide structure and monitoring to
4 prevent her from suicide and binge eating; necessary to treat her depressive disorder
5 and generalized anxiety disorder; and necessary to control her urges to binge eat, think
6 about her weight, and restricting. The “why now” factors leading to treatment involve
7 Plaintiff’s son and mentally ill girlfriend, both heroin addicts, criminal charges being
8 brought against her son, and her husband abandoning the home.
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Second, substantial evidence exists to show that inpatient treatment was not

10 medically necessary. The record shows that Plaintiff was medically stable throughout
11 the relevant time frame (except when she was admitted to the emergency room for a
12 few days in June 2014 with asceptic meningitis), and her medical history indicates that
13 she has received treatment for eating and related disorders for over 20 years. She self14 reported that her “primary problems” are binge earing, isolation, and poor body image.
15 Plaintiff also received effective treatment from June through September 2013 from
16 EDCSD.
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While the record shows that Plaintiff suffered from suicide ideation in 1997 and

18 2002, Plaintiff denied ever making a suicide attempt and denied suicide ideation when
19 she admitted to Sierra Tucson on May 13, 2014.

The psychiatric evaluation

20 emphasizes Plaintiff’s eating disorder and the stress caused by her home life. The
21 evaluation reveals that Plaintiff did not clearly express suicide ideation at that time.
22 During the period of May 19 through May 25, 2014, the nursing notes show that
23 Plaintiff repeatedly and consistently denied suicide ideation. (UBH 390, 395, 397,
24 392). Upon learning about the denial of her request for inpatient residential treatment,
25 Plaintiff claimed active suicidal thoughts for the first time.
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Finally, looking to the APA, Plaintiff fails to carry her burden. While the first,

27 third, fourth, and sixth criteria are satisfied, other criteria are not satisfied. The second
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guidelines differ.
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1 criterion requires a showing that the “member’s current condition cannot be safely
2 efficiently and effectively assessed and/or treated in a less intensive setting.” The
3 record shows that Plaintiff received effective treatments for her eating and related
4 disorders from EDCSD for the April through August 2013 time frame. The second
5 criterion requires the treatment to be clinically appropriate for the member’s condition.
6 Although Sierra Tucson recommended residential treatment for Plaintiff’s eating
7 related disorders, there is no showing that intensive outpatient treatment has been or
8 would have been any less effective in providing Plaintiff with clinically appropriate
9 treatment.
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SUMMARY
In sum, this is a sad case. The record demonstrates that when Plaintiff “self-

12 admitted” at Sierra Tucson it was because of depression and stress associated with a
13 dysfunctional family living environment and a worsening eating disorder. Suicidal
14 ideation was neither a reason motivating Plaintiff nor an evidentiary supported
15 diagnosis for the initial assessment. Only after UBH initially determined residential
16 treatment was not medically necessary did Plaintiff express suicidal thoughts and
17 mention the stockpiling of pills. A truly high risk of suicide would have demonstrated
18 mental instability and placement in an intensive inpatient facility or acute hospital for
19 evaluation, as suggested by the many board-certified psychiatrists hearing Plaintiff’s
20 appeals. Sierra Tucson never referred or transferred Plaintiff to such a facility. Finally,
21 the weight of the evidence does not support the proposition that either Plaintiff’s eating
22 disorder, or life stressors, individually or in combination, necessitated residential
23 treatment. Rather, the alternatives outlined by UBH in its final determination complied
24 with Plan requirements and Plaintiff’s needs
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For the foregoing reasons, the court finds UBH properly denied Plaintiff’s

26 request for reimbursement for residential treatment at Sierra Tucson. Specifically, the
27 medical record and evidence before the court fail to establish, by a preponderance of
28 the evidence, that the residential treatment received by Plaintiff at Sierra Tucson in
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1 May - June 2015 was medically necessary within the meaning of the Plan.
2

Judgment is awarded in favor of UBH, and against Plaintiff. The court will

3 prepare a separate judgment.
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IT IS SO ORDERED.

5 DATED: August 1, 2016
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JEFFREY T. MILLER
cc:

All parties

United States District Judge

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