Jane Doe v. Harvard Pilgrim Health Care, Inc. et al
Filing
128
Judge Denise J. Casper: ORDER entered. MEMORANDUM AND ORDER - The Court DENIES Jane's motion for summary judgment and attorney's fees and costs, D. 104, and ALLOWS HPHC's motion, D. 113. (Hourihan, Lisa)
Case 1:15-cv-10672-DJC Document 128 Filed 08/06/19 Page 1 of 32
UNITED STATES DISTRICT COURT
DISTRICT OF MASSACHUSETTS
__________________________________________
)
)
JANE DOE,
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)
Plaintiff,
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)
v.
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)
HARVARD PILGRIM HEALTH CARE, INC., )
Civil Action No. 15-10672
AND THE HARVARD PILGRIM PPO PLAN )
MASSACHUSETTS, GROUP POLICY
)
NUMBER 058866000,
)
)
Defendants.
)
)
__________________________________________)
MEMORANDUM AND ORDER
CASPER, J.
I.
August 6, 2019
Introduction
Plaintiff Jane Doe (“Jane”) has filed this lawsuit against Defendants Harvard Pilgrim
Health Care, Inc., and the Harvard Pilgrim PPO Plan Massachusetts, Group Policy Number
0588660000 (collectively “HPHC”) under the Employee Retirement Income Security Act of 1974
(“ERISA”), 29 U.S.C. § 1132(a)(1)(B), challenging HPHC’s partial denial of health insurance
benefits for residential mental health treatment. D. 1. This Court previously denied Jane’s motion
for summary judgment and allowed HPHC’s cross-motion on her claims under the HPHC health
insurance plan (the “Plan”) based upon the administrative record as of March 12, 2013. Doe v.
Harvard Pilgrim Health Care, Inc., No. 15-cv-10672-DJC, 2017 WL 4540961 (D. Mass. Oct. 11,
2017) (“Doe I”). The First Circuit reversed in part, remanded in part and vacated Doe I, holding
that the administrative record for judicial review included documents considered as part of
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HPHC’s review of Jane’s claim after the institution of this lawsuit and concluding in a denial of
benefits on February 26, 2016 (the “post-filing review”). See Doe v. Harvard Pilgrim Health Care,
Inc., 904 F.3d 1 (1st Cir. 2018) (“Doe II”). The Court now considers whether Jane’s residential
treatment, as opposed to treatment in other settings, during her first admission after February 12,
2013 was medically necessary in view of the administrative record as of February 26, 2016. For
the reasons explained below, the Court concludes that Jane has not met her burden to show by a
preponderance of the evidence that she was entitled to coverage of residential treatment during the
period of February 13, 2013 through June 18, 2013 under the Plan. The Court, therefore,
ALLOWS HPHC’s renewed motion for summary judgment, D. 113, and DENIES Doe’s motion
for summary judgment and attorney’s fees and costs, D. 104.
II.
Prior Rulings from the District Court and First Circuit
On October 11, 2017, this Court concluded that Jane’s residential treatment at the Austen
Riggs Center (“Riggs”) was not medically necessary under the Plan after February 12, 2013 where
Jane sought coverage for the full period of her first admission, from January 17, 2013 through June
18, 2013. Doe I, 2017 WL 4540961, at *11-13. The Court reviewed Jane’s medical records and
other documents up to and including March 12, 2013, when the Independent Medical Expert
Consulting Services, Inc.’s (“IMEDECS”) expert reviewer upheld HPHC’s denial of coverage for
Jane’s treatment as part of an independent external review initiated by the Massachusetts
Department of Public Health’s Office of Patient Protection (“OPP”). Id. at *10-11 (accepting “the
March 12, 2013 OPP decision as the ‘temporal cut off point’ for the administrative record”)
(citations omitted). The Court also denied Jane’s motion to expand the scope of the administrative
record to include medical records and opinions that post-dated the March 12, 2013 decision and
which HPHC had considered as part of the post-filing review culminating in a denial of Jane’s
claim on February 26, 2016. Id. at *9.
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On September 6, 2018, the First Circuit held, in relevant part here, that “the administrative
record for purposes of reviewing the benefits decision in this case includes the documents
submitted or generated as part of the post-filing review process as concluded on February 26,
2016.” Doe II, 904 F.3d at 9. The First Circuit vacated and remanded to this Court to consider
whether Jane satisfied her burden to prove her treatment was medically necessary on the expanded
administrative record. Id. at 11. Jane has now filed a renewed motion for summary judgment
along with a request for attorney’s fees and costs, D. 104, and HPHC filed a cross-motion for
summary judgment, D. 113. The Court heard the parties on the pending motions and took the
matters under advisement. D. 124.
III.
Standard of Review
“Where, as here, the plan does not unambiguously provide the administrator with
discretionary authority to determine benefit eligibility, the court’s review of the administrator’s
determination is de novo.” Kamerer v. Unum Life Ins. Co. of Am., 334 F. Supp. 3d 411, 420 (D.
Mass. 2018) (citing Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510, 517 (1st Cir. 2005)). On
summary judgment under ERISA, “the factual determination of eligibility for benefits is decided
solely on the administrative record” and the “non-moving party is not entitled to the usual
inferences in its favor.” Bard v. Bos. Shipping Ass’n, 471 F.3d 229, 235 (1st Cir. 2006) (quoting
Orndorf, 404 F.3d at 517)). “[W]here review is based only on the administrative record before the
plan administrator . . . summary judgment is simply a vehicle for deciding the issue.” Orndorf,
404 F.3d at 517.
“In reaching its decision on the record, a district court on de novo review ‘may weigh the
facts, resolve conflicts in the evidence, and draw reasonable inferences.’” Doe II, 904 F.3d at 10
(quoting Stephanie C. v. Blue Cross Blue Shield of Mass. HMO Blue, Inc., 852 F.3d 105, 111 (1st
Cir. 2017) (“Stephanie II”)). “The district judge will be asking a different question as [s]he reads
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the evidence, not whether there is a genuine issue of material fact,” but instead whether, as alleged
here, Jane’s treatment was medically necessary under the terms of the Plan. See Kearney v.
Standard Ins. Co., 175 F.3d 1084, 1095 (9th Cir. 1999). The “ERISA beneficiary who claims the
wrongful denial of benefits bears the burden of demonstrating, by a preponderance of the evidence,
that she was in fact entitled to coverage.” Stephanie II, 852 F.3d at 112-13.
IV.
Factual Background
Unless otherwise noted, all facts are undisputed and are drawn from the administrative
record (“AR”), D. 109, and the parties’ statements of fact, D. 108; D. 115; D. 117; D. 122. The
Court previously recounted the facts in Doe I and will not repeat them all here, except as necessary
for explaining the Court’s analysis.
During Jane’s freshman year of college in 2012, she suffered from anxiety and depression
and, subsequently, experienced hypomania, hallucinations and suicidal ideation. AR at 438.
Jane’s mental health deteriorated to the point that she was hospitalized on two occasions.1 AR at
442. Jane’s therapist, Audrey Rubin, M.D., referred Jane to Riggs, an out-of-network psychiatric
residential treatment center in Stockbridge, Massachusetts. Id. Riggs admitted Jane on January
17, 2013. Id. She received treatment there until June 18, 2013 (“first admission”), when she was
discharged for inpatient treatment at Berkshire Medical Center (“BMC”). AR 990. Riggs
readmitted Jane on June 24, 2013; she remained there until her discharge in August 2013 (“second
admission”). D. 115 ¶¶ 20, 23; D. 122 ¶¶ 20, 23.
1
HPHC disputes several facts alleged by Jane that contain characterizations of documents only to
the extent the document speaks for itself and does not otherwise dispute the authenticity of the
underlying document or the Court’s authority to consider the same in resolving the pending
motions discussed herein. See, e.g., D. 117 ¶ 14.
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A.
Residential Treatment at Riggs During the Relevant Time Period
1.
First Admission: January 17, 2013 through June 18, 2013
David Flynn, M.D. conducted Jane’s initial clinical assessment on January 17, 2013. AR
438-44. Jane was diagnosed with psychotic disorder NOS, mood disorder NOS and non-verbal
learning disorder. AR 440. Jane denied “current suicidal ideation, intent, or plan at the time of
admission.” AR 439. Her medication regimen at the time included Lamictal, Abilify and
Seroquel. Id. As part of the criteria met for admission to Riggs, Dr. Flynn explained that Jane had
experienced a “significant deterioration in functioning which has been unresponsive to . . .
treatment at a less intensive level of care,” AR 442; Jane possessed certain symptoms that
“mitigate[d] against successful outpatient treatment,” including suicidal behavior, self-destructive
behavior, inability to live autonomously, anxiety, depression and mania/hypomania, id.; and she
required support to a level that could not be accomplished in a less restrictive level of care,
including psychotherapy in an integrated hospital environment and twenty-four-hour nursing
observation and intervention, AR 443. Dr. Flynn, as a result, recommended Rigg’s “IRP-G”
treatment program, and noted Jane would undergo at least a “[s]ix week evaluation and treatment
admission with longer term treatment possible.” AR 443.
Jane initially experienced a difficult transition to residential treatment. AR 703 (reporting
that Jane told nursing staff she was “having a difficult time transitioning to a ‘new place’”); AR
705 (explaining that Jane had two panic attacks shortly after her admission and describing Jane’s
concern that “intense” group therapy sessions may have caused “too much stimulation around her
trauma issues”). As the month of January progressed, however, Jane engaged with peers at Riggs,
AR 704, 706; left Riggs’s campus to shop with her family, go out with friends and visited an art
store, AR 704, 706, 709-10; and she also developed a close relationship with a male resident, AR
707. Although Jane appeared to be adjusting to her new environment, she experienced what her
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treating therapist, Sharon Krikorian, M.D., described as a “manic” episode in late January. AR
448; see AR 707. On or about January 24, 2013, Jane explained that, following a stressful phone
conversation with her mother and brother, she saw “paper people coming out of the walls and
dancing and then sticking knives in her ankles.” AR 448; see AR 708. When Jane described her
hallucination to nursing staff, they noted that Jane stated that she was ready to be around other
people after reporting the incident. AR 709. Jane told staff the next day “she was feeling better”
and had made plans to go bowling with friends that evening. AR 709. Dr. Krikorian’s monthly
progress note for January indicates that Jane’s “cognition [wa]s generally intact” and “[h]er
thought process [w]as generally goal oriented,” but that she can “quickly become overwhelmed.”
AR 448. Dr. Krikorian also reported that Jane was responding “well” to an increase in her Seroquel
dosage. Id.; see AR 466.
In February 2013, Jane shopped with peers, AR 714, went “dumpster diving,” AR 726-27,
created a self-imposed art project, AR 711-12, and discussed her creative talent and the possibility
of going to art school with nursing staff, AR 732. Staff noted on several occasions, however, that
Jane was having a hard time with a male peer at Riggs with whom she had a romantic relationship.
AR 714, 718, 722, 735. Jane also continued to experience hallucinations. Jane told nursing staff
on February 10, 2013 that she “heard the voice of an older man telling her to hurt herself,” but
“was able to not give in to his words” and did not otherwise possess a suicidal “plan, means or
intent.” AR 722. Jane mentioned prior to this hallucination that she struggled with family
dynamics and her romantic relationship with a male peer, which she described as a “constant
source of anxiety since her arrival.” Id. Nursing staff placed Jane in the PAS program, which
involved moving her to a room in closer proximity to nurses and without a roommate. Id. Over
the next couple days, Jane reported that “the voice was not there” and she was glad to be near the
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nurses. AR 722-23. She “negotiated to go out” with a friend to “buy something at Staples.” AR
723. Jane’s “suicidal ideation and thoughts of cutting” were “manageable” at the time and she
denied any plan or intent of self-harm or hearing any voices. AR 725.
Jane reported another hallucination on February 25, 2013, when she approached nursing
staff and stated she felt “snakes on [her] legs.” AR 733. Jane explained that, despite the
hallucination, she knew she was safe and she had no intention of harming herself. Id. Later that
day, she was observed interacting with peers and reported “doing better . . . than she was earlier in
the day.” Id. Dr. Mintz posited that Jane’s hallucinations of snakes on her body might relate to
experiences of akathisia from her Seroquel prescription. AR 1046. Dr. Mintz also worried that
Jane’s psychotic symptoms related to a seizure disorder, which could be exacerbated by Seroquel’s
lowering of her seizure threshold. AR 476. By this time, Riggs had revised Jane’s diagnosis from
“bipolar to schizoaffective disorder” and “added hysteria and partial complex seizures to the
differential, particularly given the atypical nature of [Jane’s] hallucinations . . . and a dramatic
quality to some of her symptomatic displays, which increased in the context of interpersonal
experiences of loss or rejection.” AR 1046. On February 27, Jane told nursing staff she was
“experiencing delusions around people outside of Riggs, hiding in bushes, watching her and
waiting to hurt her.” AR 734-35. Dr. Krikorian’s monthly progress note for February suggests
that Jane’s mental health may have been impacted by Jane’s romantic relationship with a male
peer. AR 450. Riggs nonetheless approved Jane for medication self-administration on February
28. AR 543.
Jane did not report any hallucinations or manic episodes in March or April. See AR 452;
AR 454. Jane told nursing staff in early March that she wanted to “come off all [her] meds and
have a clear mind” and that she was frustrated with the community at Riggs. AR 742. Her
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frustration and desire to leave Riggs coincided with issues in her romantic relationship with a male
peer. AR 736-37; see AR 742; AR 746; AR 751. In April, however, Jane travelled to New York
to visit a male peer, who had been discharged from Riggs. AR 772. Upon her return, Jane reported
feeling “good enough” and looking forward to “starting a new medication to see if this may help
her be more creative and better than ‘good enough.’” AR 777. A few days later, on April 20, 2013
and in reaction to the Boston Marathon bombings, Jane told nursing staff “she wishes she could
act out on her homicidal feelings like he did, but knows the consequences and would never do
that.” AR 779. By April 22, 2013, Jane had resumed her routine at Riggs and was observed in
common areas engaging with peers and staff. AR 782.
Jane made a few trips home in April and May 2013. In late April, Jane went home to visit
her family for a few days. Jane reported afterwards that home was “awful.” AR 785. Jane
nonetheless went home again for knee surgery between May 2, 2013 and May 5, 2013. AR 79092. She declined an offer to talk to nursing staff upon her return to Riggs, AR 792, and later
explained that she thought her trip “went well,” AR 794. Despite complaints of intense “midday
sedation” in connection with a medication change and partial loss of consciousness, AR 912, Jane
requested a pass to spend the week with her family from May 24, 2013 through May 28, 2013, AR
803. Jane described this visit as enjoyable despite the fact that she “fainted” which she attributed
to stress. AR 968.
Beginning in late May, Jane reported losing consciousness and fainting spells while at
Riggs. AR 968-75. On June 6, 2013, Jane wandered away from Riggs and explained afterwards
that she was chasing a hallucinated giraffe down the street. AR 977-78. Jane explained that her
symptoms, including the hallucinations and loss of consciousness, might be related to a seizure
disorder based upon her conversations with Dr. Mintz. AR 977. Dr. Mintz had identified the
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possibility of seizure disorders soon after Jane was admitted to Riggs, and he stressed that it was
important to determine whether Jane’s symptoms “have [a] neurological basis.” AR 466. Jane
had the appointment for an EEG to determine whether she had a seizure disorder on June 4. See
AR 974. Jane expressed concern regarding the outcome of her EEG while awaiting the results,
which she hoped would confirm the seizure disorder diagnosis. AR 972. Jane explained to nursing
staff that she preferred this diagnosis because of its “concrete[ness]” and because she wanted to
“have a condition that is treatable.” Id.; see AR 974. According to Dr. Mintz’s pharmacology
notes, he believed Jane’s hallucinations in June occurred “in the context of a disruption in an
interpersonal relationship with a male peer.” AR 916. Around the same time, Jane’s relationship
with another male peer at Riggs grew “complicated” and she discussed the same with nursing staff.
AR 972, 979.
Jane’s EEG did not show any seizure activity. AR 918. On June 11, Jane reported feeling
“very weird, scared, and tearful” and “disappointed” after receiving the results of the EEG, which
indicated that she did not have a seizure disorder. AR 983; AR 949. Jane continued to express
her disappointment with the the results of her EEG over the next few days. AR 984, 986. On June
18, 2013, Jane was found lying on the floor of her room with bloody scratches on her leg. AR
989. Nursing staff found a broken razor on the sink. Id. Jane explained that she was trying to
write “kill” on her leg with the razor and had experienced a frightening hallucination prior to
cutting herself. Id. After staff determined that Jane was an immediate danger to herself, she was
transported for inpatient psychiatric evaluation in a locked unit at BMC. AR 990. While there,
physicians discontinued Jane’s prescription for Geodon, and prescribed Clozaril, an antipsychotic
medication. AR 1028.
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2.
Second Admission: June 24, 2013 through August 2013
Jane was discharged from BMC and returned to Riggs on June 24, 2013. AR 1045. Dr.
Krikorian noted that Jane “struggle[d] with complicated and powerful feelings about family,
friends, [and her] therapist that she expresses through psychotic process.” AR 1036. In a monthly
progress note for June, Dr. Krikorian stated that Jane’s cognition was grossly intact and she denied
suicidal and homicidal ideation or intent. AR 1038. In July, Dr. Krikorian reported that Jane
continued to have visual hallucinations, but was less overtly angry and did not possess suicidal
ideation or intent. AR 1039. Jane told nursing staff in late July that she felt like her Clozaril
prescription was “starting to show some positive results” and that she had been “waking up in a
good space and having productive days with some delusions.” AR 1185. Dr. Krikorian suggested
that, no earlier than August 7, 2013, Jane’s psychosis and behavior could be safely managed and
adequately treated at a lower level of care. AR 1246. HPHC does not dispute that Jane’s
residential treatment at Riggs during the second admission, between June 24, 2013 and August 7,
2013, was medically necessary.
B.
HPHC’s Coverage Determinations for Jane’s Residential Treatment
HPHC agreed to cover a portion of Jane’s first admission to Riggs, including the period
from January 17, 2013 to February 12, 2013, and all of her second admission from June 24, 2013
to August 7, 2013. Based upon review of Jane’s mental health history, medical records from
Riggs, conversations with Jane’s clinicians and medical opinions generated as part of the postfiling review, HPHC maintains—and Jane disputes—that residential treatment during the first
admission after February 12, 2013 was not medically necessary as defined under the Plan.2
2
The Plan defines medical necessity as follows:
[t]hose health care services that are consistent with generally accepted principles of
professional medical practice as determined by whether: (a) the service is the most
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1.
HPHC’s Initial Coverage through February 5, 2013
At the time of Jane’s treatment, HPHC contracted with United Behavioral Health (“UBH”)
to manage mental health benefits and review initial coverage determinations for HPHC Plan
beneficiaries. AR 89-94. HPHC utilized UBH’s Optum Level of Care Guidelines (“Guidelines”)
to determine whether requested mental health treatment was medically necessary and, therefore,
covered under the Plan. Id. The Guidelines indicate that the Plan covers “[r]esidential services .
. . delivered in a facility or a freestanding Residential Treatment Center that provides overnight
mental health services to members who do not require 24-hour nursing care and monitoring offered
in an acute inpatient setting but who do require 24-hour structure.” AR 89. To qualify for
residential treatment level of care, one of the following criteria must be met:
(1) the member is experiencing a disturbance in mood, affect or cognition resulting
in behavior that cannot be safely managed in a less restrictive setting; or (2) there
is an imminent risk that severe, multiple and/or complex psychosocial stressors will
produce significant enough distress or impairment in psychological, social,
occupational/educational, or other important areas of functioning to undermine
treatment in a lower level of care; or (3) the member has a co-occurring medical
disorder or substance use disorder which complicates treatment of the presenting
mental health condition to the extent that treatment in a residential treatment center
is necessary.
Id.
HPHC approved initial coverage of Jane’s treatment at Riggs on January 18, 2013. AR
232. Relying upon the initial assessment conducted by Riggs’ clinicians, HPHC found that Jane
appropriate supply or level of service for the Member’s condition, considering the
potential benefit and harm to the individual; (b) the service is known to be effective,
based on scientific evidence, professional standards and expert opinion, in
improving health outcomes; and (c) for services and interventions that are not
widely used, the use of the service for the Member’s condition is based on scientific
evidence.
AR 21-22.
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satisfied at least one of the above mentioned criteria, noting (among other things) that Jane had
previously expressed suicidal intent with “plans to jump off roof or [overdose],” had four psychotic
episodes, multiple inpatient admissions in the previous year and poor responses to medication. Id.
Jane initially requested coverage for twenty-eight days of residential treatment; HPHC approved
coverage for seven days (i.e., until January 23, 2013). AR 95, 231-32.
HPHC extended Jane’s coverage through February 5, 2013 based upon conversations
between Dr. Krikorian and UBH clinician, Martin Rosenzweig, M.D., as part of UBH’s peer-topeer review process on January 29, 2013. AR 95-100; AR 272. Dr. Krikorian explained that Jane
needed the “structure of residential as she needs nursing support when she is unable to sleep and
her parents do not have the ability to help her when she is home.” AR 272. Dr. Krikorian stated
that although Jane was not “currently actively suicidal” at the time and was “able to sustain her
safety in an unlocked residential setting,” she did not meet Riggs criteria for “step down to [partial
hospitalization programs].” Id. Dr. Rosenzweig, nonetheless, concluded that Jane was not
meeting the criteria for continued residential care and could be readied to step down to partial
hospitalization. Id. He approved three additional days of residential treatment for the purpose of
preparing a good discharge plan with the involvement of Jane’s parents. Id. UBH case notes from
January 31, 2013, prior to the next scheduled peer-to-peer review, indicate that Riggs clinicians
reported there was “nothing new to add” from UBH’s last review of Jane’s condition and that there
were no changes to her medication regimen during this time. AR 278.
2.
Denial of Continued Coverage for Residential Treatment from February
13, 2013 through June 18, 2013
On February 4, 2013, James W. Feussner, M.D., Associate Medical Director of UBH,
performed a peer-to-peer review with Dr. Krikorian to assess whether continued residential
treatment at Riggs was medically necessary, AR 305, and consistent with the Guidelines, which
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require that Plan beneficiaries meet six criteria to warrant continued coverage, including, as is
relevant here: (1) “criteria for the current level of care continue to be met” and (6) “member’s
current symptoms and/or history provide evidence that relapse or a significant deterioration in
functioning would be imminent if the member was transitioned to a lower level of care or, in the
case of outpatient care, was discharged,” AR 93-94. Dr. Krikorian again reported that Jane was
not actively suicidal or psychotic and noted that she had “improved” with her “medication
regimen,” which had not been adjusted in two weeks. AR 305-306. Dr. Krikorian maintained,
however, that Jane should continue residential treatment at Riggs for four-to-six weeks for an
evaluation and then her clinicians at Riggs would determine how long she needed to stay there for
treatment. AR 306. Dr. Feussner concluded that Jane did not meet the residential treatment level
of care criteria set forth in the Guidelines. AR 310. Accordingly, in a letter dated February 5,
2013, HPHC explained that effective February 6, 2013, Jane’s residential treatment at Riggs would
no longer be covered under the Plan. AR 404. The letter quoted Dr. Feussner’s assessment, stating
Jane’s “acute crisis bringing [her] to the hospital has quieted” and that “[a]lthough [Jane]
continue[d] to have challenges in dealing with stressors and relationships, [she] [was] able to move
towards recovery . . . and [did] not appear to need further help from residential level of care. [She]
can continue to work on healthy coping strategies with [her] Mental Health Partial Hospitalization
Services.” AR 404-405.
Following the February 5, 2013 denial of continued coverage, Jane initiated an expedited
internal appeal pursuant to which Michael Bennett, M.D., a UBH physician and board-certified
psychiatrist, considered Jane’s medical history and UBH case notes, including relevant peer-topeer reviews, and discussed Jane’s condition with Dr. Krikorian. AR 409-10. During their
conversation, Dr. Krikorian stated that Jane’s “voices have returned, although not as intensely as
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before,” that there “may be a change in mediation,” and that Riggs viewed the goal of treatment
as helping Jane “deal with [her] feelings in a long-term, protected setting.” AR 409. Dr. Bennett,
nonetheless, found that Jane was “not currently psychotic and not suicidal and has improved on
her current medications” and concluded on February 12, 2013 that Jane might be “safely able to
pursue treatment while living at home and attending outpatient treatment, beginning with [partial
hospitalization programs].” Id. Continued residential treatment, therefore, was not medically
necessary as Jane did not meet continued service criteria one and six. Id. In a letter, dated February
12, 2013, HPHC explained that based on Dr. Bennett’s review, its denial of coverage for residential
treatment was being upheld on appeal, but that treatment during the pendency of the appeal, i.e.,
February 6, 2013 through February 12, 2013, would be covered. AR 410.
Having exhausted HPHC’s internal review process, Jane appealed to the OPP, which
retained IMEDECS to conduct an independent, external review of Jane’s claim. AR 424-29.
IMEDECS independent expert, who is not identified by name, was described as a board-certified
adult and child psychiatrist and an assistant clinical professor of psychiatry who also maintained a
private practice in a psychiatric hospital. AR 433. The independent expert considered Jane’s
medical history, including prior hospitalizations and threats of suicide, as well as her medical
records from Riggs and the UBH Guidelines. AR 434-35. On March 12, 2013, IMEDECS
informed Jane that the independent expert reviewer upheld HPHC’s determination “in full” given
“there was no evidence that [Jane] required 24 hour supervision or nursing care” as of February
13, 2013, and she denied active suicidal or homicidal ideation. AR 435. According to the
independent expert, the symptoms described in Jane’s medical records were not severe enough to
prevent her from participating in treatment at a lower level of care such as a partial hospitalization
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program. Id. Jane’s appeal process culminated in the OPP’s conclusion that residential treatment
at Riggs was not medically necessary as of February 13, 2013. Id.
Later on October 18, 2013, Dr. Krikorian submitted a letter to HPHC asserting that the
residential treatment Jane received between February and June 2013 was medically necessary and
appropriate “given the particular nature of her illness and the unsuccessful consequence of other
treatments efforts.”3 AR 1239. The letter indicated that, as of June 2013, Jane had been diagnosed
with schizoaffective disorder, post-traumatic stress disorder, learning disability NOS and
personality disorder NOS. AR 1240. Due to these diagnoses, Dr. Krikorian stated that Jane
“needed an environment that provided support and enough structure . . . to allow her to do intensive
treatment necessary . . . to resolve her significant difficulties and learn to prevent future
deterioration.” AR 1241. Dr. Krikorian explained further that Riggs is “such an environment,”
with its “open, voluntary, residential treatment facility,” including twenty-four-hour nursing
availability. Id. As further support for Dr. Krikorian’s assessment that Jane’s residential treatment
at Riggs was medically necessary, she described Jane’s psychotic episodes and hallucinations
during the period for which coverage was denied, including when Jane reported hearing a “male
voice telling her to harm herself” on February 10, 2013. AR 1242. Dr. Mintz acknowledged,
however, that “[o]ther things” suggested that Jane’s symptoms might be “hysterically elaborated,”
including “the coincidence of her symptoms” with interpersonal challenges with her peers. AR
1244.
3
In a letter, dated January 15, 2014, Dr. Krikorian asserted that Jane’s treatment at Riggs between
June 24, 2013 and August 7, 2013 was also medically necessary. D. 109-1 at 635. Given that
HPHC agreed to cover Jane’s treatment during this period, the Court does not address the January
2014 letter here.
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3.
Post-filing Review
After the institution of this action on March 12, 2015, HPHC agreed to additional
administrative review of Jane’s claim for coverage. AR 1264-66. Accordingly, HPHC’s Medical
Director, Joel Rubinstein, M.D., considered medical records from Jane’s first admission, see AR
1329, UBH records, HPHC records and clinical discussions with Dr. Krikorian and Dr. Mintz. AR
1264-66. The report prepared by Edward Darell, M.D., an HPHC clinician who determined that
Jane’s second admission at Riggs was medically necessary on February 19, 2014, was also
included in the administrative record. See AR 1324, 1261-63. On September 28, 2015, Dr.
Rubinstein became the third clinician (after Drs. Feussner and Bennett) to conclude that Jane could
have been stepped down to a lower level of care as of February 13, 2013. AR 1264-66.
Jane submitted the medical opinions of Gregory Hines, M.D., an independent medical
reviewer hired by Jane to opine on the medical necessity of her treatment, and Eric Plakun, M.D.,
Director of Admissions and Associate Medical Director for Riggs, in response to Dr. Rubinstein’s
opinion. AR 1267, 1281, 1330. In a letter dated February 26, 2016, HPHC’s general counsel sent
a letter to Jane’s counsel affirming its denial of Jane’s claim. AR 1327-31.
V.
Discussion
A.
The Administrative Record
This Court previously held that Jane did not meet her burden of demonstrating that
residential treatment at Riggs during the first admission after February 12, 2013 was medically
necessary based upon the Court’s review of medical records and opinions up to and including
March 12, 2013, when OPP upheld HPHC’s denial of coverage for residential treatment as part of
an independent, external review process. Doe I, 2017 WL 4540961, at *10-12. In light of the First
Circuit’s ruling in Doe II, the Court now considers whether Jane’s continued residential treatment
during the first admission after February 12, 2013 was medically necessary in view of “the
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documents submitted or generated as part of the post-filing review process as concluded on
February 26, 2016,” including “[Jane’s] medical records from both admission to Riggs, as well as
the reports of Dr. Darrell [sic], Dr. Harris, Dr. Plakun, and Dr. Krikorian.” Doe II, 904 F.3d at 9.
HPHC contends, as a preliminary matter, that medical records and opinions post-dating the
OPP’s decision on March 12, 2013 upholding HPHC’s denial of continued coverage are not
relevant here even though the First Circuit concluded such documents are part of the administrative
record. D. 114 at 9-11. HPHC argues that these documents “simply shed no light on Doe’s
condition at the time of [HPHC’s] denial,” therefore, the Court need not consider them in its de
novo review. Id. at 10. The First Circuit’s decision in Doe II establishes February 26, 2016 as
HPHC’s final administrative decision and the “temporal cut off point” for judicial review. Doe II,
904 F.3d at 6 (quoting Orndorf, 404 F.3d at 519 (explaining that “the final administrative decision
acts as a temporal cut off point” such that a “claimant may not come to a court and ask it to consider
post-denial medical evidence in an effort to reopen the administrative decision”)). On February
26, 2016, HPHC provided “concluding remarks” on the post-filing review process, as well as a
description of documents and reasoning underlying this final administrative decision denying
coverage for Jane’s stay during the first admission at Riggs after February 12, 2013. AR 1327.
HPHC determined that the residential treatment “for this entire period” was not medically
necessary based upon “treatment records up through June 17, 2013;” id., Dr. Rubinstein’s
assessment from September 28, 2015, including conversations Dr. Rubinstein had with Drs.
Krikorian and Mintz, AR 1329; and additional documents submitted by Jane on December 3, 2015,
including the opinions of Drs. Harris and Plakun, AR 1329, AR 1326. Although not mentioned in
HPHC’s February 2016 letter, HPHC agreed as of August 13, 2015 to include other documents in
its post-filing review, including (1) a letter from Jane dated February 19, 2014, attached medical
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records from January 17, 2013 through August 14, 2013 and opinions from Dr. Krikorian dated
October 17, 2013 and January 15, 2014; and (2) a clinical review report prepared by Dr. Darell on
February 19, 2014. See AR 1324 (explaining that “the parties’ agreed-to parameters of HPHC’s
medial review” include Jane’s February 19, 2014 letter, exhibits attached thereto and Dr. Darell’s
medical report).
To the extent HPHC now contends that such documents are not relevant here, the Court
rejects that argument given HPHC’s consideration of these documents as part of its final decision
as to Jane’s residential treatment through June 18, 2013 and the First Circuit’s conclusion that the
same should be reviewed as part of the administrative record. Although the Court will not discount
all documents post-dating the March 12, 2013 OPP decision (as HPHC suggests is appropriate), it
recognizes that certain documents bearing upon Jane’s mental ailments during her second
admission, for example, may have less probative value than medical records and opinions
concerning the medical necessity of Jane’s residential treatment during her first admission. See
Weisner v. Liberty Life Assurance Co. of Bos, 192 F. Supp. 3d 601, 614 (D. Md. 2016) (explaining
that the district court on de novo review of a decision denying benefits “must resolve questions of
material fact, assess expert credibility, and—most critically—weigh the evidence”); see also
Bethany Coleman-Fire v. Standard Ins. Co., No. 3:18-CV-00180-SB, 2019 WL 2011039, at *9 (D.
Or. May 7, 2019) (stating that “[w]hen a court engages in de novo review, it may evaluate and give
credence to the [evidence] that it finds more reliable and probative”).
B.
Medical Necessity
The Court does not seek to diminish the seriousness or severity of Jane’s symptoms during
the relevant time period or the need for her continued psychiatric treatment, even if it were not
exclusively in a residential treatment setting as disputed by the parties here. The “correctness, not
the reasonableness, of [HPHC’s] denial of [Jane’s] benefits is [the Court’s] only concern” on de
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novo review. Johnson v. Am. United Life Ins. Co., 716 F.3d 813, 819 (4th Cir. 2013). After a
close review of the record, the Court concludes that Jane has not met her burden to prove by a
preponderance of the evidence that residential treatment at Riggs was medically necessary from
February 13, 2013 through June 18, 2013.
1.
Necessity of Residential Treatment Level of Care under the Plan
The Court is not persuaded that Jane’s symptoms required a residential treatment level of
care during the relevant period based upon this record. Treatment that is medically necessary
under the Plan must be, among other things, “the most appropriate . . . level of service for the
Member’s condition, considering the potential benefit and harm to the individual.” AR 22. UBH
Guidelines define residential treatment as “[r]esidential services . . . delivered in a facility or a
freestanding Residential Treatment Center that provides overnight mental health services to
members who do not require 24-hour nursing care and monitoring offered in an acute inpatient
setting but who do require 24-hour structure.” AR 89. Residential treatment level of service is
appropriate at least where (1) the “member is experiencing a disturbance in mood, affect or
cognition resulting in behavior that cannot be safely managed in a less restrictive setting,” (2)
“there is imminent risk that severe, multiple and/or complex psychosocial stressors will . . .
undermine treatment in a lower level of care” or (3) the “member has a co-occurring medical
disorder or substance use disorder which complicates treatment” to the extent that residential
treatment is necessary. Id. The parties do not contend, and the Court has not otherwise concluded,
that Jane had a medical disorder or substance use disorder that necessitated residential treatment
as described in the last consideration for residential level treatment of care. The Court, therefore,
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addresses whether residential treatment was necessary under the first or second prong of the
Guidelines for residential treatment level of care.4
a)
Jane’s Symptoms Could Be Safely Managed in a Less Restrictive
Setting
Jane contends that her symptoms could not have been managed in a less restrictive setting
because she required the twenty-four-hour structure of residential treatment at Riggs. D. 105 at 58, but the administrative record reveals that such twenty-four-hour structure was not medically
necessary.
Jane argues that residential treatment (and, by extension, its twenty-four-hour structure)
was necessary because she regularly sought help from Riggs’s nursing staff, especially in evenings
or at night. Id. (collecting examples of Jane’s interactions with nursing staff in the evening, at
night and early morning). Jane asks the Court to consider, for example, that on February 10 and
June 6, 2013, Jane was admitted to Riggs’s PAS program, which involved relocating to a different
room in closer proximity to nursing staff and/or closer monitoring and patient safety assessments.
AR 722-25, 977. In connection with her relocation to a PAS room, Jane told nursing staff that she
“fe[lt] safe being so close to the nurses [sic] station,” AR 723, and that “PAS was very helpful,”
AR 725. On both occasions resulting in her admission to the PAS program, however, Jane had
previously alerted staff to her need for additional monitoring and support during normal working
hours. AR 722 (indicating that Jane was moved to a PAS room after speaking with nursing staff
at 2:25 p.m.); AR 976 (explaining that, on June 5, 2013 at 1:24 p.m., less than twelve hours before
4
The Court has considered Jane’s Notice of Supplemental Authority, D. 126, and HPHC’s
response to same. D. 127. Since that authority, Dominic W. v. The Northern Trust Co. Employee
Welfare Benefit Plan and Health Care Serv. Corp., 2019 WL 2576558, at *1 (N.D.Il. June 24,
2019), involved different guidelines regarding medical necessity and distinctive factual
circumstances concerning Sofia W.’s treatment and progress, the analysis in that case does not
compel a different outcome here.
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she chased a hallucinated giraffe down the street, Jane told nursing staff she was “doing poorly,”
believed she had a “psychotic episode” and was “becoming more paranoid”). That is, even in a
less restrictive environment, including a partial hospitalization program that does not provide
twenty-four-hour structure, Jane could have accessed nursing staff during the day to develop a plan
for safely managing her symptoms should they escalate or become more pronounced at night.
Even if the record indicated that provision of PAS services to Jane was helpful, such provision
does not compel a conclusion that another level of care would have been inappropriate here.
The Court’s inquiry requires focusing not on whether Jane took advantage of and/or
benefited from the structure and support offered in residential treatment, but, rather, whether such
level of care was medically necessary. See, e.g., Stephanie II, 852 F.3d at 117 (explaining because
ERISA plans are “a form of contract,” the inquiry is not whether one’s treatment was beneficial to
her, “but, rather, whether that course of treatment was covered under the Plan”). Although
overnight monitoring and proximity to nursing staff was apparently helpful on the occasions Jane
was admitted to PAS over the course of five months, the record indicates that Jane was often able
to manage her symptoms without utilizing services unique to residential treatment. Jane regularly
declined additional monitoring or support, even after potentially triggering events, in favor of time
alone in her room, simply talking to nurses or therapy. See, e.g., AR 718; AR 719; AR 733; AR
734-35; AR 741; AR 746-50; AR 772; AR 779. On most days, moreover, Jane either did not
interact with nursing staff or engaged in casual conversation regarding her day. See, e.g., AR 73641 (providing Jane’s interactions with nursing staff between March 1, 2013 and March 7, 2013).
Jane demonstrated in other ways that she did not require the twenty-four-hour structure of
residential treatment during the disputed time period. She frequently left Riggs’s campus in the
evenings and spent several nights off campus to visit family and friends. Jane went skiing with
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friends, AR 725, 738; shopping, AR 744; to a concert, AR 747; dumpster diving with friends, 726;
to the movies, AR 796; and to an antique show, AR 799. She spent nearly twenty days away from
Riggs for vacations and medical appointments during her first admission. See, e.g., AR 760, 77275, 783-84, 789, 803-806.
The record also includes examples in which the twenty-four-hour structure of residential
treatment, including the proximity to and required engagement with other residents, seemed to
have a negative impact on Jane’s mood and behavior. Jane expressed reservations early on about
the rigors of group therapy in residential treatment. See AR 705; AR 560. She also had several
interpersonal issues with her peers. See AR 506; AR 742 (explaining that Jane was feeling badly
in the community); AR 772.
Where, as here, the totality of the record show that although Jane required continued
treatment, she did not need the twenty-four-hour structure of residential treatment by at least
February 13, 2013, and other conditions of residential treatment at Riggs seemed to negatively
impact Jane’s treatment, the Court concludes, even on this expanded record, that Jane’s symptoms
could have been safely managed in less restrictive treatment.
b)
Record Shows There was not an Imminent Risk of Psychosocial
Triggers That Would Undermine A Lower Level of Care for Jane
On this expanded record, the Court also cannot conclude that there was imminent risk that
psychosocial stressors would have undermined her transition to a lower level of care between
February 13, 2013 and June 18, 2013. Jane argues, in relevant part here, that her parents were ill
equipped to respond to her symptoms and “unstable reactions” to engaging with family. D. 105 at
8. As an initial matter, the record indicates that the symptoms initially prevented Jane from
receiving a lower level of care while living at home with her family had diminished in intensity by
early February. In 2012, Jane’s family reported not feeling comfortable overseeing her care after
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she climbed atop the roof of their three-story home and considered jumping off despite being under
her family’s “nearly 24-hour supervision.” AR 1240. Jane was hospitalized shortly thereafter. Id.
When Jane was admitted to Riggs in 2013, Dr. Flynn reported her symptoms requiring residential
treatment as including suicidal behavior, self-destructive behavior, inability to live autonomously,
depression and anxiety and mania/hypomania. AR 442.
After weeks of psychotherapy sessions, twenty-four-hour nursing observation and
intervention, group therapy, see AR 443, and an increase in Seroquel to which Jane “responded
well,” AR 448, however, Jane no longer exhibited at least three of the symptoms responsible for
her referral to residential treatment at Riggs. First, Jane was not suicidal or psychotic, as noted by
her treating therapist, Dr. Krikorian. AR 392. Second, Jane did not appear to have engaged in
self-destructive behavior. Although she reported some hallucinations and thoughts about cutting
herself, she did not take “aggressive” action, AR 450, and went to nursing for help, AR 480. Third,
Jane displayed an ability to live autonomously, including by leaving Riggs for activities with
friends. See, e.g., AR 705-706, 709-10, 714, 723. Finally, Jane’s medication regimen had helped
with her anxiety, AR 476, she was less prone to manic-like experiences, AR 450, and depression
was not among the symptoms described in the February reports prepared by her therapist and
psychopharmacologist. See AR 450-51, 474-77.
As to the impact of family interactions on Jane’s symptomology, during the initial clinical
assessment conducted by Dr. Flynn, Jane described her family as close with a vulnerability towards
anxiety but did not otherwise attribute her symptoms to family dynamics. AR 438; see AR 504.
In early February, as part of another psychosocial assessment, a Riggs social worker observed that
Jane’s family was supportive and open to seeking out resources for each member despite
challenging dynamics. AR 499. Consistent with this assessment, Jane’s parents engaged with
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Riggs clinicians throughout her treatment and took advantage of family therapy sessions. See AR
494-99, 920-23. Dr. Bennett, who denied Jane’s appeal of HPHC’s denial of coverage, described
Jane’s family as supportive in concluding that she “might be safely able to pursue treatment while
living at home and attending outpatient treatment, beginning with [partial hospitalization].” AR
409. On the other hand, one of the first hallucinations of Jane’s first admission occurred shortly
after learning that her little brother was not doing well, AR 708, and she expressed a desire to cut
while recounting perceived family pressure, AR 722. Jane’s responses to trips home also varied.
Compare AR 785 with AR 794. Jane nevertheless was able to manage any negative feelings
towards family through conversations with nursing staff and her therapist. Moreover, there is no
indication that the family therapy sessions that Jane and her parents found helpful in residential
treatment would not have been available at a lower level of care.
c)
Continued Treatment at the Residential Treatment Level of Care
Was Not Medically Necessary
The Court also concludes that Jane was not entitled to continued coverage for treatment
during the first admission after February 12, 2013 under the UBH Guidelines “Continued Service
Criteria.” AR 93. The Guidelines anticipate that as the severity of a Plan beneficiary’s symptoms
diminish, the beneficiary will no longer meet the criteria for her current level of care and can be
safely transitioned to another level of care. Id. HPHC considers six criteria in determining whether
continued service at the current level is appropriate. Id. (explaining that beneficiaries must meet
all six criteria for continued coverage). For the reasons previously mentioned, Jane no longer
satisfied the residential level of care standard as required by the first criteria for continued
coverage. Id. (requiring that “(1) The criteria for the current level of care continue to be met”).
Continued coverage for the first admission for residential treatment at Riggs was not medically
necessary after February 12, 2013 for the additional reason that Jane’s symptoms at the time did
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not evidence “relapse or a significant deterioration in functioning would be imminent if [she] was
transitioned to a lower level of care.” AR 94. Between Jane’s admission on January 17, 2013 and
HPHC’s denial of continued coverage effective as of February 13, 2013, Jane experienced one
episode described as “manic” on January 24, 2013. AR 448. Jane’s treatment at Riggs was
covered for nearly three weeks after that incident and, during that time, she responded positively
to an increase in Seroquel, noting a decrease in manic-like symptoms for the month of February in
general. AR 450. Dr. Krikorian also noted that Jane was not suicidal or psychotic by February 4,
2013, and that she improved with the assistance of adjustments to her medication. AR 305. There
was also one period when Jane was monitored more closely by nurses as part of the PAS program
between the more concerning January 24, 2013 delusion and the end of her residential treatment
coverage in February. See AR 722. The period was brief and Jane was able to seek help and
report the problem rather than act on it. AR 722-225. She negotiated outings with friends several
times, even during this period of monitoring. Id. By February 13, 2013, Jane reported that her
thoughts of cutting were “manageable,” she denied any “plan or intent of self-harm,” and denied
hearing voices. AR 725. For these reasons, the evidence in this record does not indicate that Jane
met the criteria for continued residential treatment level of coverage under the Plan.
2.
The Medical Opinions
In its analysis, the Court has considered the medical opinions submitted by Drs. Krikorian,
Plakun, Harris, Darell and Rubinstein, which were added to the administrative record as part of
the post-filing review. Jane contends that, apart from Dr. Rubinstein, the remaining opinions
indicate that the entirety of Jane’s first admission was medically necessary. The Court does not
agree.
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a)
Dr. Krikorian
Dr. Krikorian provided two letters of support for coverage of the entirety of Jane’s
residential treatment. Only the first letter, dated October 18, 2013, concerns Jane’s first admission
between January 17, 2013 and June 18, 2013. AR 1239-45. Dr. Krikorian states that Jane’s
residential treatment was medically necessary during this first admission because of her complex
symptomology, need for twenty-four-hour structure and her inability to control her psychosis with
adjustments to her medication. Id. First, while the Court credits Dr. Krikorian’s assessment of
Jane’s disorders, the letter at issue does not suggest that Jane’s symptomology could not be safely
managed in less restrictive setting, for one example, a partial hospitalization program. Dr.
Krikorian opines as to the incompatibility of Jane’s symptoms with “psychiatry treatments that are
solely focused on rapid stabilization such as 5 day inpatient treatments” or “crisis-focused
hospitalizations.” AR 1241. This would explain why hospitalization in an acute setting would not
serve Jane’s long-term interest in managing her symptoms but does not appear to bear upon
whether Jane could have been stepped down to a lower level of care without compromising her
safety between February 13, 2013 and June 18, 2013.
Second, for the reasons previously stated, the Court concludes based upon the entirety of
the record, that Jane did not require twenty-four-hour structure during the disputed time frame.
Dr. Krikorian acknowledged Jane’s difficulties with the structural restrictions of residential
treatment in monthly progress notes during the first admission. See AR 450 (noting Jane’s
disagreement with “examined living” and “falsely comply[ing]” with aspects of her program in
February); AR 452 (asserting that Jane had “felt embroiled in a number of community issues” in
March); AR 454 (stating that Jane “felt lost in the community” and had “re-established a
connection with another male patient” with whom she discussed “dark emotions and ways to
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commit suicide” in April); AR 908 (indicating that Jane spoke about not wanting to see Dr.
Krikorian treat other patients).
Third, as to Jane’s responses to medication, neither Drs. Krikorian nor Mintz have
explained why Jane was not prescribed Clozaril during her first admission, especially given Jane’s
positive responses to this antipsychotic after it was prescribed during her hospitalization in June
2013. See AR 1185 (explaining that the Clozaril prescription was “starting to show some positive
results” and that Jane had been “waking up in a good space and having productive days with some
delusions”). Regardless, even as Jane adjusted to changes in her medication, she was often able
to communicate her symptoms before acting on them or causing harm to herself and others prior
to the incident on June 18 that led to her hospitalization and discharge from Riggs.
For these reasons, the Court is not persuaded that Dr. Krikorian’s opinion overcomes the
evidence on the other side of the scale. In ERISA cases, treating physicians are not entitled to
special deference. Doe I, 2017 WL 4540961, at *13 (citing Richards v. Hewlett-Packard Corp.,
592 F.3d 232, 240 (1st Cir. 2010), cert. denied, 562 U.S. 1102 (2010); Orndorf, 404 F.3d at 526;
see Gernes v. Health & Welfare Plan of Metro. Cabinet, 841 F. Supp. 2d 502, 510 (D. Mass. 2012);
Jon N. v. Blue Cross Blue Shield of Mass., 684 F. Supp. 2d 190, 203 (D. Mass. 2010)). In addition,
it is unclear what internal criteria Dr. Krikorian considered in arriving at her conclusions regarding
medical necessity, whether they differ from HPHC’s and to what degree.
b)
Dr. Darell
On February 19, 2014, Edward W. Darell, M.D. overturned HPHC’s denial of coverage
for Jane’s residential treatment from June 24, 2013 and August 7, 2013. AR 1261-63. He
concluded that residential treatment was medically necessary during this time period given that
Jane “would not be able to tolerate a lower level of care such as outpatient treatment . . . and would
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most likely decompensate and place herself and others at risk.” AR 1263. He noted, however,
that at the time of his review and despite Jane’s “history of decompensating over a 2 year period,”
she did “not appear to present an imminent danger to herself or others.” Id. Given that Dr. Darell
did not consider whether Jane should have received coverage for residential treatment between
February 13, 2013 and June 18, 2013, the period at issue here, and the Court’s conclusion that the
preponderance of the evidence relevant to this period indicates that residential treatment was not
medically necessary, the Court is not inclined to extend Dr. Darell’s analysis beyond the context
he provided.
c)
Dr. Harris
Jane has provided an independent medical review report, dated December 1, 2015, and
prepared by Gregory G. Harris, M.D. AR 1272-1331. Dr. Harris, who was retained by Jane’s
counsel, reviewed treatment records from Riggs as well as correspondence and administrative
records from HPHC. AR 1272. He also spoke with Jane’s mother, Dr. Krikorian and Dr. Mintz.
Id. Dr. Harris did not examine Jane at any time relevant to this litigation. Id. Dr. Harris’s letter
does not provide new information regarding the medically necessity of Jane’s residential treatment.
Instead, Dr. Harris responds to Dr. Rubinstein’s concerns regarding the reliability of Riggs’s
diagnosis, AR 1273, and the scientific basis underlying Riggs’s residential treatment program for
individuals with Jane’s disorders, AR 1274. The Court has considered Dr. Harris’s opinion about
the medical necessity of Jane’s residential treatment at Riggs during the time period at issue, AR
1281; see AR 1276, however, for the reasons previously discussed and the balance of the record
here, the Court is not persuaded by Dr. Harris’s reiteration of the argument that Jane required
twenty-four-hour structure, AR 1277.
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d)
Dr. Plakun
On November 29, 2015, Eric M. Plakun, M.D., Associate Medical Director of Admissions
at Riggs, explained that “a reasonable person who reviewed the evidence would conclude that the
‘open setting’ residential treatment model developed and used . . . Riggs meets the standard of
care” for residential psychiatric treatment. AR 1271. Even assuming that this is correct, the Court
concludes on this record that residential treatment level of care for the portion of her first admission
at issue here was not medically necessary as discussed above.
C.
Attorneys’ Fees and Costs
1.
Considering Eligibility for Attorneys’ Fees
ERISA provides that claimants seeking relief may recover “reasonable attorney’s fee and
costs” at the court’s discretion. 29 U.S.C. § 1132(g)(1). Although some statutory schemes
providing for the recovery of attorneys’ fees require that such recovery is only available to the
“prevailing party,” see, e.g., 42 U.S.C. § 1988(b), ERISA requires only that the claimant achieve
“some degree of success on the merits.” Hardt v. Reliance Std. Life Ins. Co., 560 U.S. 242, 245
(2010). A claimant does not satisfy this requirement by achieving “trivial success on the merits”
or a “purely procedural victory.” Id. at 255 (citation and alterations omitted). In Hardt, the
Supreme Court acknowledged that the claimant had persuaded the district court that the plan
administrator did not comply with ERISA guidelines and that she “did not get the kind of review
to which she was entitled under applicable law,” resulting in the district court remanding the matter
to the plan administrator, which eventually reversed its decision and awarded the claimant benefits.
Id. at 255-56. In light of the district court’s determination, the Supreme Court concluded that the
claimant earned “far more” than a purely procedural or trivial victory and was, therefore, entitled
to attorneys’ fees. Id. at 256. The Supreme Court declined to decide whether “whether a remand
order, without more, constitutes ‘some success on the merits’ sufficient to make a party eligible
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for attorney’s fees under § 1132(g)(1).” Id. at 256.
The First Circuit in Gross v. Sun Life Assurance Co., 763 F.3d 73 (1st Cir. 2014) explained
that while “it is unnecessary . . . to adopt a position on whether remand alone is enough to trigger
fees eligibility . . . [a] remand to the claims administrator for reconsideration of benefits entitlement
ordinarily will reflect the court’s judgment that the plaintiff’s claim is sufficiently meritorious that
it must be reevaluated fairly and fully.” Gross, 763 F.3d at 78. There, the First Circuit’s remand
instructions required the district court to order rendering of a new decision from the plan
administrator based upon medical evidence that was not “fairly examined during the original
administrative process.” Id. Gross is distinguishable from the instant litigation, where the plan
administrator, HPHC, willingly conducted a full review of documents that were not part of the
administrative record when Jane instituted the litigation. Here, the Court did not consider these
additional records in Doe I, but there was no suggestion that the administrator had failed to do so.
The First Circuit remanded to this Court to consider these documents included in the
administrator’s post-filing review. By contrast to the First Circuit’s remand in Doe II, the remand
in Gross was “functionally the same” as if the remand to the plan administrator “had been ordered
in the first instance by the district court.” Gross, F.3d at 78 n.6 (explaining that there was no
distinction between the “[First Circuit’s] remand to the district court in [Gross], directing a remand
to the claims administrator” and Hardt, where “the remand at issue was directly from the district
court to the claims administrator”).
Jane nonetheless argues that Gross is relevant here because the First Circuit did not limit
fee awards to parties who secured a remand to a plan administrator; rather, attorneys’ fees may be
appropriate where “an ERISA beneficiary has earned a second look at her claim based on a
deficient first review” regardless of whether “the identified flaw is explicitly linked by the
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remanding court to a statute or regulation.” D. 105 at 18 (quoting Gross, 763 F.3d at 79). Jane
appears to suggest that Gross supports a fee award where, as here, the district court is asked to
reconsider the merits on a record that includes post-filing review documents previously considered
by the plan administrator in denying the underlying benefits claim. This case appears to be
distinguishable as well from Gross where the First Circuit noted that the second look worthy of
fee eligibility is one that affords the beneficiary a “second chance for ‘a full and fair review’ of
her claim by the plan administrator,” Gross, 763 F.3d at 79, which is not the case here.
2.
Whether an Award of Attorneys’ Fees is Warranted
Even assuming arguendo that Hardt and Gross apply and Jane is eligible for an award of
attorneys’ fees, the Court concludes that such award is not warranted here. “Eligibility for
attorney’s fees is not sufficient to entitle a party actually to receive attorney’s fees, however, in the
First Circuit, a five-factor test is used to review fee requests under ERISA.” Hatfield v. Blue Cross
& Blue Shield of Mass., Inc., 162 F. Supp. 3d 24, 44 (D. Mass. 2016) (citing Gross, 763 F.3d at
83). These factors are: “(1) the degree of culpability or bad faith attributable to the losing party;
(2) the depth of the losing party’s pocket, i.e., his or her capacity to pay an award; (3) the extent
(if at all) to which such an award would deter other persons acting under similar circumstances;
(4) the benefit (if any) that the successful suit confers on plan participants or beneficiaries
generally; and (5) the relative merit of the parties’ positions.” Cottrill v. Sparrow, Johnson &
Ursillo, Inc., 100 F.3d 220, 225 (1st Cir. 1996).
Here, the first factor does not weigh in favor of granting attorneys’ fees. The Court does
not conclude that HPHC acted in bad faith by challenging Jane’s attempt to add documents to the
administrative record that were previously considered as part of a review initiated only by
agreement of the parties after the institution of this litigation. The second factor weighs in Jane’s
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Case 1:15-cv-10672-DJC Document 128 Filed 08/06/19 Page 32 of 32
favor to the extent HPHC does not contest its ability to pay. D. 114 at 22. However, “capacity to
pay, by itself, does not justify an award.” Cottrill, 100 F.3d at 226-27. The Court does not believe
the third factor, deterrence, weighs in favor of a fee award. Fees may have a deterrent effect by
discouraging plan administrators from denying meritorious claims. Here, although Jane prevailed
in having a remand to this Court regarding the proper scope of the record for judicial review, this
Court ultimately has upheld HPHC’s decision to deny the claim. The fourth factor also does not
weigh in favor of a fee award because the First Circuit’s remand requiring the Court to review
Jane’s claim on an expanded administrative record has no discernible benefit to plan participants
who will not necessarily share the unique circumstance of the post-filing review at issue by HPHC
in this case. Finally, the final factor, the relative merits of the parties’ positions, also does not
weigh in favor of awarding attorneys’ fees. Although Jane’s position as to the scope of the
administrative record was successful in the First Circuit, she has not satisfied her burden on the
merits of her claim for all of the reasons discussed above. Given the balance of these factors, the
Court denies Jane’s request for attorneys’ fees and costs.
For the foregoing reasons, the Court DENIES Jane’s motion for summary judgment and
attorney’s fees and costs, D. 104, and ALLOWS HPHC’s motion, D. 113.
So Ordered.
/s/ Denise J. Casper
United States District Judge
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