B. et al v. Connecticut General Life Insurance Company et al

Filing 31

MEMORANDUM DECISION AND ORDER granting 21 Motion for Summary Judgment. Signed by Judge Bruce S. Jenkins on 4/3/2017. (las)

FILED
2017 APR 3 PM 1:24
CLERK
U.S. DISTRICT COURT
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF UTAH

JOHN B., LINDA B., and MATTHEW B.,
Plaintiffs,

v.
CONNECTICUT GENERAL LIFE
INSURANCE COMPANY, CIGNA
BERAVI ORAL HEALTH and INTEL
CORPORATION MEDICAL BENEFIT
PLAN,

MEMORANDUM DECISION AND
ORDER

Case No. 1:16-CV-00041-BSJ
District Judge Bruce S. Jenkins

Defendants.

This matter came before the court for hearing on March 23, 2017. Brian S. King appeared
on behalf of Plaintiffs John B., Linda B., and Matthew B. (collectively "B. Family"). James L.
Barnett and Jack M. Englert appeared on behalf of Defendants Connecticut General Life
Insurance Company and Cigna Behavioral Health, Inc. (collectively "Cigna") and Defendant
Intel Corporation Medical Benefit Plan ("Plan").
Having considered the parties' briefs, the evidence presented, the arguments of counsel,
and the relevant law, the court finds that Cigna's decision to deny coverage of Matthew B.'s
residential treatment at Island View Residential Treatment Center ("Island View") after March 6,
2013 was not arbitrary and capricious.
As such, Defendants' combined summary judgment motion is GRANTED.

BACKGROUND
The Plan is a self-funded employee benefit plan sponsored by Intel Corporation. Cigna is
the Plan's claims administrator. During the time period relevant to this case, Matthew B. was a
covered dependent under the Plan.
In order for medical services to be covered under the Plan, such services must meet
Cigna's guidelines for medical necessity. In the Cigna Standards and Guidelines/Medical

Necessity Criteria for Treatment of Behavioral Health and Substance Use Disorders ("Cigna
Standards and Guidelines"), the following "basic elements of medical necessity" are identified
for residential mental health treatment for children and adolescents:
[H]ealth care services that a Provider, exercising prudent clinical
judgment, would provide to a patient for the purpose of evaluating,
diagnosing or treating an illness, injury, disease or its symptoms, and that
are:
a) Required to meet the essential health needs of the patient;
b) Consistent with the diagnosis of the condition for which they are
required;
c) Consistent in type, frequency and duration of treatment with
scientifically-based guidelines as determined by medical research;
d) Required for purposes other than the convenience of the provider
or the comfort of the patient;
e) Rendered in the least intensive setting that is appropriate for the
delivery of health care.
Rec. 332.
In addition, the Cigna Standards and Guidelines identify criteria that children and
adolescents, once admitted to a residential treatment facility, must meet for continued stay:
1. The individual continues to meet all basic elements of medical
necessity.

One or more of the following criteria must be met:
A. The treatment provided is leading to measurable clinical
improvements in acute symptoms and a progression towards
discharge from the present level of care, but the individual is
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not sufficiently stabilized so that he/she can be safely and
effectively treated at a less restrictive level of care, OR
B. If the treatment plan implemented is not leading to measurable
clinical improvements in acute symptoms and a progression
towards discharge from the present level of care, there must be
ongoing reassessment and, modification to the treatment plan,
when clinically indicated, OR
C. The individual has developed new symptoms and/or behaviors
that require this intensity of service for safe and effective
treatment.

All of the following must be met:
D. The individual and family are involved to the best of their
ability in the treatment and discharge planning process.
E. Continued stay is not primarily for the purpose of providing a
safe and structured environment.
Rec. 336.
On February 1, 2013, Matthew B. was admitted to Island View. According to Island
View's records, "Matt was admitted to Island View after he had shown increased difficulty with
managing his emotions including refusing to go to school, threatening [his] mother, breaking
objects around the house, engaging in little to no activities outside of the home, and only doing
something if [his] parents would buy him something." Rec. 622.
On February 5, 2013, Island View contacted Cigna for Plan authorization for Matthew
B.'s residential treatment at Island View. Cigna concluded that Matthew B. appeared to
minimally meet the Cigna Standards and Guidelines, and Cigna approved coverage for seven
days ofresidential treatment. Rec. 505. On February 7, February 18, and February 27, Cigna
contacted Island View and on each occasion Cigna approved Matthew B. for additional days of
residential treatment at Island View. Rec. 506-09.
On March 6, 2013, updated clinical information indicated that Matthew B. continued to
have depression and anxiety but he presented "improved communication with [his] parents," was

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"more active with some peers," and was no longer suicidal, homicidal, or psychotic. Cigna found
that Matthew B. could be safely maintained through outpatient treatment. Rec. 509-510. Cigna
determined Matthew B. no longer met the Cigna Standards and Guidelines for continued
treatment at Island View and denied coverage for such treatment after March 6. Id.
Island View requested a peer-to-peer telephone conference to discuss Cigna's
determination. Cigna referred Matthew B. 's case to Prest & Associates, Inc.-who in tum
referred the case to Dr. Kenneth Marks-to have an independent psychiatrist participate in the
telephone conference with Island View.
On March 7, 2013, after participating in the telephone conference with Island View, Dr.
Marks found as follows:
In my opinion, the CIGNA Behavioral Health level of care
guidelines for Continued Stay at Adolescent Mental Health
Residential Treatment level of care are no longer met as of
03/07/13 as the patient did not display any type of risky or risktaking behavior that was putting him or others at danger. He was
displaying no type of behavior at that time that needed 24-hour
care, supervision, observation, and contaimnent. The patient could
be treated at the mental health outpatient level of care from
03/07/13 and forward.
The treatment provided has led to sufficient stabilization of [the
patient's] symptoms so that [he] can be safely and effectively
treated at a less restrictive level of care.
Less restrictive levels of care are available for safe and effective
treatment.
Rec. 514. Later that day, Dr. Stuart Lustig, a Cigna on-staff psychiatrist, reviewed clinical notes,
the peer review discussion with Island View, and Dr. Marks' determination and found that he
was "in full agreement that medical necessity criteria are not met for [mental health residential
treatment]." Rec. 515.

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Notwithstanding Cigna's denial of coverage, Matthew B. continued his treatment at
Island View and was not discharged until September 11, 2013, shortly before his eighteenth
birthday. Rec. 622.
On Febrnary 26, 2014, the B. Family submitted an appeal of Cigna's claim
determination. On March 7, 2014, Dr. Frederick Green, a Cigna on-staff psychiatrist, reviewed
the appeal and found as follows:
Based upon the available clinical information received initially and
with this appeal, your symptoms did not meet Cigna's Behavioral
Health Medical Necessity Criteria for continued stay at Residential
Mental Health Treatment for Children and Adolescents level of
care from 03/07/2013 - 09/11/2013 as the treatment provided had
led to sufficient stabilization of your symptoms so that you could
be safely and effectively treated at a less restrictive level of care.
You had not developed new symptoms and/or behaviors that
required this intensity of service for safe and effective treatment.
There was no new focused intervention proposed to address what
appeared to be your ongoing reactivity to different environmental
situations. Although it is acknowledged that you continue to show
occasional opposition, there was not evidence that you continued
to improve your ability to deal with frnstration and that stability
was largely determined by the structure of the environment. Your
continued stay was primarily for the purpose of providing a safe
and structured environment. Less restrictive levels of care were
available for safe and effective treatment.
Rec. 519.
Following receipt of Cigna's appeal detennination letter, the B. Family requested on July
7, 2014 an external review by an Independent Review Organization. Cigna forwarded the request
to MCMC, an Independent Review Organization, who assigned the review to Dr. Michael Cesta.
On July 15, 2014, Dr. Cesta submitted his independent review report, which found as
follows:
Based on the clinical information, medical necessity would not be
met for the residential level care on the dates in question. Firstly,
the patient would not meet medical necessity for admission to the

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residential level of care. On the specific dates in question there is no
evidence that the patient was dangerous, violent, aggressive,
suicidal, homicidal, psychotic, manic, or profoundly disabled.
to
indicate
that
the
patient's
There's
nothing
psychopharmacological and psychotherapeutic interventions could
not have occurred in the exact same fashion an outpatient setting.
There is nothing to indicate why the patient would require 24 hour
monitoring to receive psychotherapy and medications. The patient
was not dangerous, violent, or behaving a fashion that jeopardized
himself or other people. The patient did not have severe comorbid
diseases, getting treatment. There simply is no indication why 24hour monitored environment is required to manage this patient's
psychiatric illness which could be done in the home environment
while he attends appropriate psychotherapy and other outpatient
services. Therefore, medical necessity is not met.
Rec. 490.
On April 5, 2016, the B. Family filed a Complaint under 29 U.S.C. § 1132(a)(l)(B)
seeking payment of benefits for Matthew B.'s treatment at Island View that were allegedly
required under the Plan and that were allegedly inappropriately denied. 1
DISCUSSION

"[A] denial of benefits challenged under§ l 132(a)(l)(B) is to be reviewed under a de
nova standard unless the benefit plan gives the administrator or :fiduciary discretionary authority

to determine eligibility for benefits or to construe the terms of the plan."2 "If the plan does
explicitly confer discretionary authority on an administrator ... courts must review benefit
determinations under an 'arbitrary and capricious' standard." 3
As the parties agree, the Plan provides Cigna with discretionary authority to detennine
eligibility for benefits, and the appropriate standard ofreview for denial of benefits is thus abuse

1

See Compl., filed April 5, 2016 (CM/ECF No. 2) at 8-9.

2

Firestone Tire &Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989).

3

Geddes v. United Staffing All. Employee Med. Plan, 469 F.3d 919, 923 (10th Cir. 2006) (citing Chambers
v. Family Health Plan, 100 F.3d 818, 825 (10th Cir.1996)).

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of discretion. 4 "Under the abuse of discretion, or arbitrary and capricious, standard, the denial
'decision will be upheld unless it is not grounded on any reasonable basis."' 5 Indeed, "[t]he
Administrator's decision need not be the only logical one or even the best one. It need only be
sufficiently supported by facts within his knowledge to counter a claim that it was arbitrary or
capricious." 6
After reviewing the materials in the administrative record in light of this deferential
standard of review, and after considering the arguments of counsel, the court determines that
Cigna had sufficient reasonable basis for denying coverage of Matthew B.' s residential treatment
at Island View after March 6, 2013. In order for Matthew B. 's continued treatment at Island
View to qualify for coverage under the Plan, such treatment needed to be "[r]equired to meet the
essential health needs of [Matthew B.]" and "[r]endered in the least intensive setting that is
appropriate for the delivery of health care." Rec. 332. There is sufficient evidence in the record
of improvement and stabilization in Matthew B. 's situation for Cigna to reasonably conclude that
Matthew B.'s treatment could be continued in a less intensive setting.

4

See Reply Mem. in Supp. of Pls.' Mot. for Summ. J., filed March 2, 2017 (CM/ECF No. 27) at 2.

5

Hancockv. Metro. Life Ins. Co., No. 2:06-CV-00882DAK, 2008 WL 2996723, at *7 (D. Utah Aug. 1,
2008) (footnote omitted) (quoting Kimber v. Thiokol, 196 F.3d 1092, 1098 (10th Cir.1999)), ciffd, 590 F.3d 1141
(10th Cir. 2009).
6

Id.

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CONCLUSION

The court finds that Cigna's decision to deny coverage of Matthew B.'s residential
treatment at Island View after March 6, 2013 was grounded on a sufficiently reasonable basis
and therefore was not arbitrary and capricious. As such, Defendants' summary judgment motion
is GRANTED.
Let judgment be entered accordingly.

.t}YDATED this_,
__ day of April, 2017.

istrict Judge

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