J. et al v. United Healthcare Insurance et al

Filing 85

MEMORANDUM DECISION and Order: The court GRANTS IN PART Plaintiffs motion 67 and DENIES Defendants motions 65 66 . The court REMANDS the benefits determination from July 1, 2019 to January 24, 2020 to Defendants for further revi ew of Plaintiffs benefits claim consistent with this Memorandum Decision and Order. The court does not address the parties cross-motions for summary judgment on the MHPAEA claim because this order has rendered the issue moot. Signed by Judge David Barlow on 09/24/2024. (kpf)

THE UNITED STATES DISTRICT COURT
DISTRICT OF UTAH
C.J. and F.R.,
Plaintiffs,
v.
UNITED HEALTHCARE INSURANCE
COMPANY, UNITED BEHAVIORAL
HEALTH, CIGNA HEALTH and LIFE
INSURANCE COMPANY, CIGNA
BEHAVIORAL HEALTH, and the
PITTSBURGH FOUNDATION BENEFITS
PLAN,

MEMORANDUM DECISION AND ORDER
DENYING DEFENDANTS’ [65, 66]
MOTIONS FOR SUMMARY JUDGMENT
AND GRANTING IN PART PLAINTIFFS’
[67] MOTION FOR SUMMARY
JUDGMENT
Case No. 2:22-cv-00092
District Judge David Barlow
Magistrate Judge Cecilia M. Romero

Defendants.

Before the court are the parties’1 cross-motions for summary judgment.2 Plaintiffs C.J.
and F.R. (collectively “Plaintiffs”) sued Defendants Cigna Health and Life Insurance Company,
Cigna Behavioral Health (collectively “Cigna”), and the Pittsburgh Foundation Benefits Plan
(“the Plan”) under the Employee Retirement Income Security Act of 1974 (“ERISA”) and the
Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”).3 For the reasons below,
the court grants in part Plaintiffs’ motion and denies Defendants’ motions.

1

On December 12, 2023, Plaintiffs voluntarily stipulated to dismiss Defendants United Healthcare Insurance
Company and United Behavioral Health with prejudice. ECF No. 57.
2
Cigna’s Mot. Summ. J., ECF No. 65, filed February 5, 2024; Pittsburgh Foundation’s Mot. Summ. J., ECF No. 66,
February 5, 2024; Pls.’ Mot. Summ. J. (“Pls.’ MSJ”), ECF No. 67, filed February 5, 2024. Pittsburgh Foundation’s
motion for summary judgment “is based entirely on the arguments presented by Cigna in its motion for summary
judgment” and incorporates by reference all of Cigna’s arguments. ECF No. 66. Therefore, the court cites solely to
Cigna’s motion, ECF No. 65, which it refers to as “Defs.’ MSJ.”
3
Compl., ECF No. 2, filed February 14, 2022.

BACKGROUND
Plan Structure, Coverage, and Level of Care Guidelines
Plaintiff C.J. participated in an employee welfare group health insurance plan (“the
Plan”) governed by ERISA.4 As a dependent of C.J.,5 F.R. was a beneficiary under the Plan.6
Cigna is the Claims Administrator for the Plan, which “delegates to Cigna the discretionary
authority to interpret and apply Plan terms and to make factual determinations in connection with
its review of claims under the Plan.”7
The Plan covers treatment for varying levels of outpatient and inpatient mental healthrelated services.8 Outpatient care is the least restrictive and applies when the beneficiary is not
confined in a hospital.9 Outpatient care includes partial hospitalization services, which provides
services for “not less than 4 hours and not more than 12 hours in any 24-hour period by a
certified/licensed mental health program,” as well as intensive outpatient programs (“IOP”),
which provides “a combination of individual, family and/or group therapy in a day, totaling 9 or
more hours in a week.”10 On the other hand, inpatient mental health treatment is the most
restrictive and covers services that are provided by a hospital when a beneficiary is confined in a
hospital for treatment and evaluation of mental health.11 Inpatient care includes Residential
Treatment Services, which are provided by a hospital for the evaluation and treatment of

4

Administrative Record (“AR”) 4133, ECF No. 64.
C.J. is F.R.’s mother.
6
Compl. ¶ 6.
7
AR 4133.
8
AR 4153.
9
Id.
10
Id.
11
Id.
5

psychological and social functional disturbances that are a result of subacute mental health
conditions.12
The Plan defines a Mental Health Residential Treatment Center (“RTC”) as an institution
which:
specializes in the treatment of psychological and social disturbances that are a
result of mental health conditions; provides a subacute, structured,
psychotherapeutic treatment program, under doctor supervision; provides 24-hour
care, in which a person lives in an open setting; and is licensed in accordance with
the laws of the appropriate legally authorized agency as a residential treatment
center.13
Under the Plan, benefits are covered if Cigna determines them to be Medically
Necessary. The Plan defines Medically Necessary as:
Healthcare services, supplies and medications provided for the purpose of
preventing, evaluating, diagnosing or treating an Illness, Injury, condition, disease
or its symptoms, that are all of the following as determined by a Medical Director
or Review Organization:
 required to diagnose or treat an Illness, Injury disease or its symptoms; and
 in accordance with generally accepted standards of medical practice; and
 clinically appropriate in terms of type, frequency, extent, site and duration;
and
 not primarily for the convenience of the patient, Doctor or health care
provider; and
 rendered in the least intensive setting that is appropriate for the delivery of the
services, supplies or medications. Where applicable, the Medical Director or
Review Organization may compare the cost-effectiveness of alternative
services, supplies, medications or settings when determining the least
intensive setting.14
To evaluate coverage of RTC level of treatment for children and adolescents, Cigna uses
the Cigna Standards and Guidelines/Medical Necessity Criteria for Residential Mental Health

12

Id.
Id.
14
AR 4182.
13

Treatment for Children and Adolescents (“Residential Treatment Guidelines”). Under these
guidelines, all of the following must be met for admission to an RTC:
1. All elements of Medical Necessity must be met.
2. The child/adolescent has been diagnosed with a moderate-to-severe mental
health disorder, per the most recent version of the Diagnostic and
Statistical Manual of Mental Disorders and evidence of significant
distress/impairment.
3. This impairment in function is seen across multiple settings such as:
school, home, work, and in the community, and clearly demonstrates the
need for 24 hour psychiatric and nursing monitoring and intervention.
4. As a result of the interventions provided at this level of care, the
symptoms and/or behaviors that led to the admission can be reasonably
expected to show improvement such that the individual will be capable of
returning to the community and to a less restrictive level of care.
5. The child/adolescent is able to function with age-appropriate
independence, participate in structured activities in a group environment,
and both the individual and family are willing to commit to active regular
treatment participation.
6. There is evidence that a less restrictive or intensive level of care is not
likely to provide safe and effective treatment.15
Cigna’s Residential Treatment Guidelines further specify that, in order for continued
RTC stay to be covered under the Plan, the child receiving treatment must “continue to meet all
elements of Medical Necessity.”16 Additionally, all of the following must be met: “(A) The
child/adolescent and family are involved to the best of their ability in the treatment and discharge
planning process; (B) Continued stay is not primarily for the purpose of providing a safe and
structured environment; and (C) Continued stay is not primarily due to a lack of external
supports.”17 Lastly, one or more of the following criteria must be met:
A. The treatment provided is leading to measurable clinical improvements in
the moderate-to-severe symptoms and/or behaviors that led to this
admission and a progression toward discharge from the present level of
15

AR 4226.
AR 4227.
17
Id.
16

care, but the individual is not sufficiently stabilized so that he/she can be
safely and effectively treated at a less restrictive level of care,
B. If the treatment plan implemented is not leading to measurable clinical
improvements the moderate-to-severe symptoms and/or behaviors that led
to this admission and a progression toward discharge from the present
level of care, there must be ongoing reassessment and modifications to the
treatment plan that address specific barriers to achieving improvement,
when clinically indicated,
C. The individual has developed new symptoms and/or behaviors that require
this intensity of service for safe and effective treatment.18
If a beneficiary disagrees with an initial coverage determination, the Plan provides an
internal appeal process.19 If the beneficiary’s claim is again denied, the beneficiary may either
appeal through an external review program or bring legal action.20
Pertinent Medical History
F.R.’s mental health struggles began in 2009 when she was five or six years old.21 That
year, her father attempted suicide and her parents separated a few months later.22 To deal with
this trauma, F.R. began receiving art therapy and general therapy treatments with Ursula
Schwartz, Ph.D. on and off until 2016 when F.R. was in 7th grade.23 In 2016, F.R. became
increasingly concerned with her appearance and developed the irrational belief that her face was
asymmetrical.24 This belief became so consuming that F.R. began refusing to leave the house.25

18

AR 4227.
AR 4120.
20
AR 3519.
21
AR 81, 140. Defendants dispute how Plaintiffs “selectively cite F.R.’s medical history” and “do not cite to any
contemporaneous medical records” prior to F.R.’s admission to Solacium New Haven (an RTC) on February 15,
2019. Defs.’ MSJ. at 5. The court does not base its coverage decision on these pre-2021 events, but instead includes
these facts as useful background and because they were supplied to and considered by Cigna in Plaintiffs’ first-level
appeal of Cigna’s denial letter. See AR 3516–17 (stating that Cigna’s reviewer reviewed the appeal).
22
AR 81.
23
Id.
24
Id.
25
Id.
19

On April 9, 2016, C.J. took F.R. to the hair salon for a haircut that F.R. wanted.26 During
the haircut, she had a panic attack—characterized by a tearful outburst, shortness of breath, and
dizziness—which resulted in C.J. taking F.R. to a local psychiatric hospital for an evaluation.27
She was then taken to University of Pittsburgh Medical Center (“UPMC”), where the evaluator
noted that F.R. was depressed, anxious, had not been going to school due to poor self-esteem,
had suicidal thoughts with no plan or intent, experienced a lack of appetite, and was not
sleeping.28
From September 6 to November 10, 2016, F.R. had her first round of ObsessiveCompulsive Disorder (“OCD”) intensive outpatient (“IOP”) treatments with an intense focus on
exposure response prevention to help her overcome her body dysmorphic disorder.29 At this
point, she was discharged, returned to school, and began seeing several therapists and
psychiatrists at UPMC’s Family and Children’s Center.30
To help manage her depression, F.R. enrolled in a partial hospitalization program
(“PHP”).31 However, according to C.J., instead of her treatment helping her, F.R. began to
express increasing suicidal ideation and anxiety.32 F.R. withdrew from the PHP and re-enrolled
in the OCD IOP from September 19 to October 16, 2017,33 but her suicidal ideation and selfharm behaviors increased alarmingly.34 As a result, her therapists recommended that she enroll in

26

Id.
Id., AR 138.
28
AR 138.
29
AR 82.
30
Id.
31
Id.
32
AR 82.
33
AR 270–71.
34
AR 82–83.
27

the Suicidal Teens at Risk (STAR) Program for intensive therapy from October to November
2017.35 On November 9, 2017, F.R. was discovered to be engaging in acts of self-harm,
including making three to six-inch knife cuts on her calves and shins, which resulted in her first
hospitalization for six days.36
From November 2017 to November 2018, F.R. received treatment at the Children and
Adult Bipolar Spectrum Disorder Clinic.37 In addition, from December 2017 to July 2018, C.J.
and F.R. participated in family-based therapy, which included two to three home visits per week
for eight weeks.38 In the fall of 2018, F.R. transitioned to receiving weekly therapy from Amy
Schlonski, a licensed clinical social worker and Board Certified Diplomate in Clinical Social
Work.39 According to C.J., F.R.’s condition did not substantially improve.40 During this period,
F.R.’s anger increased significantly, including screaming and becoming physical with C.J. when
asked to do ordinary tasks like homework, chores, and going to school.41 F.R. would bang her
head on the wall, furniture, and floor, lunge for objects with which to harm herself, and threaten
to run away.42 She also stopped going to school on a regular basis.43 Ms. Schlonski broached the
idea of enrolling F.R. in a residential treatment program because she was not responding to the
current treatment.44

35

AR 83, 387.
Id., AR 373–80, 387, 83.
37
AR 83.
38
Id.
39
Id.
40
Id.
41
AR 84.
42
Id.
43
Id.
44
Id.
36

Admission to New Haven
On November 23, 2018, F.R.’s father committed suicide.45 After her father’s death, F.R.
became more suicidal and depressed.46 Although her mother locked up all sharp objects, she
began finding F.R. hiding sharp objects in her room.47 From January 7, 2019 to January 18,
2019, F.R. re-enrolled in the STAR IOP program.48 On January 20, 2019, C.J. discovered that
F.R. was texting friends about her plans to hang herself in the closet (the same way her father
died).49 C.J. took F.R. to the hospital where she stayed from January 20, 2019 to January 29,
2019.50
On February 15, 2019, F.R. was admitted to Solacium New Haven (“New Haven”),51 an
RTC.52 At New Haven, therapist Andrew Hines listed three diagnoses in the Master Treatment
Plan: Major Depressive Disorder, Obsessive-Compulsive Disorder, and Generalized Anxiety
Disorder.53 First, he described her anxiety that most noticeably included perfectionist thoughts,
such as putting herself down over not doing things in a precise manner and only seeing the
negative side of a situation.54 Second, he described F.R.’s difficulty regulating her emotions as a

45

Id.
Id.
47
Id.
48
AR 84–85.
49
AR 85.
50
Id., 524
51
AR 907, 910, 912.
52
Cigna summarily states in its opposition to Plaintiffs’ facts that New Haven is not an RTC. Defs.’ MSJ 4. Cigna
devotes only a single sentence to this assertion, which does not appear in its argument section. As Cigna does not
include this reason in any of its denial letters, this unsupported contention is not relevant. The court also notes that
New Haven’s website’s homepage states “We are a residential treatment center . . . ” New Haven,
https://www.newhavenrtc.com/ [https://perma.cc/5JK9-RX5H] (last visited Sept. 17, 2024); see also Labertew v.
WinRed, Inc., No. 2:21-CV-555-TC, 2022 WL 1568924, at *7 (D. Utah May 18, 2022) (“Courts have taken judicial
notice of information posted on websites.”); Joseph F. v. Sinclair Servs. Co., 158 F. Supp. 3d 1239, 1245 (D. Utah
2016) (identifying New Haven as “a licensed residential treatment facility.”).
53
AR 3242, 3265.
54
AR 3243.
46

direct cause of anxiety and obsessions.55 Third, Mr. Hines described F.R.’s obsessions and
compulsions as part of her OCD diagnosis, such as obsessing over doing something perfectly,
fretting that nothing is ever good enough, and believing most of the things she does impact other
people in a negative way.56
Care at New Haven
F.R. remained at New Haven from February 15, 2019 to January 24, 2020.57 The
recommended treatment care included weekly individual therapy, weekly family therapy, daily
group participation, full participation in the values program, active participation in recreational
therapy, therapeutic assignments, family weekends and therapeutic home passes, a monthly
meeting with the consulting psychiatrist to evaluate anxiety and medication, various forms of
residential support, experiential support, meeting with an academic advisor, and assessing and
treating any incidents of self-harm.58 The master treatment plan also included a number of
objectives, such as learning skills to cope and manage her symptoms, identifying and exploring
patterns in her mood, and completing a minimum of three successful home passes.59
New Haven provided treatment summaries throughout F.R.’s time there.60 In June 2019,
F.R.’s treatment summary indicated that she wrote a “concerning” letter to her mother “regarding
mood/anxiety symptoms a week prior to her period including [suicidal ideation].”61 On June 26,
2019, Mr. Hines, F.R.’s therapist, observed that F.R. continues to report on “high levels of

55

Id.
AR 3244.
57
AR 912, 3555.
58
AR 3242–46.
59
Id.
60
AR 3535–37.
61
AR 3536.
56

anxiety constantly, obsessive thoughts about inadequacy and body image, [and] constant worry
about school failure” and these “symptoms and behaviors demonstrat[e] the continued need for
RTC level of care.”62 On July 3, 2019, directly after a home pass for F.R.’s mother’s wedding,
F.R.’s therapist repeated the concerns from the June 26, 2019 session, including that F.R.’s
“symptoms and behaviors demonstrat[e] the continued need for RTC level of care.63 Although
the specific symptoms varied over time, F.R.’s therapist noted that F.R.’s “symptoms and
behaviors demonstrat[e] the continued need for RTC level of care” on multiple dates in July
2019,64 August 2019,65 September 2019,66 October 2019,67 and November 2019,68 In this July 3,
2019 therapy session, however, Mr. Hines also noted that “[F.R.] used the skills she learned the
previous sessions to be able to come home in a good mood and continue with her routine at the
home and in school.”69
Also on July 3, 2019, F.R. filled out a self-questionnaire that involved reading statements
and describing how true the statement was during the prior seven days.70 F.R. had to choose
between checking “Never or Almost Never,” “Rarely,” “Sometimes,” “Frequently,” and “Almost
Always or Always.”71 The results of the questionnaire were somewhat mixed.72 For example,
F.R. reported “frequently”: (i) feeling anxious or nervous;73 (ii) having strong and quickly

62

AR 1576.
AR 4018.
64
AR 3341, 3348, 3980.
65
AR 2950, 3353.
66
AR 2735, 2786, 2839, 2919, 3355.
67
AR 2552, 2621, 2649.
68
AR 3367, 3371.
69
Id.
70
AR 4020.
71
AR 4020–35.
72
The court notes that the answers in this questionnaire may be partially affected by F.R. having just returned from a
home trip celebrating her mother’s wedding. See AR 3343.
73
AR 4023.
63

changing emotions;74 (iii) pouting, crying, or feeling sorry for herself more than others her age;75
(iv) feeling irritated;76 (v) getting down on herself and blames herself for things that go wrong;77
and (vi) getting frustrated or easily upset and giving up.78 She also reported “Almost Always or
Always” feeling guilty when she does something wrong79 and not forgiving herself for things she
has done wrong.80 In addition, when asked how often she had been bothered by the following
problems in the past two weeks, F.R. responded that on “Several days” she felt “down,
depressed, or hopeless,” felt bad about herself—or that she was a failure or let herself or her
family down.81
In contrast, in the same self-questionnaire, F.R. responded “Never or Almost Never” in
response to whether she cut classes or skips school;82 had physical fights with adults, family, or
others her age;83 steals or lies;84 sees, hears or believes things that are not real;85 has hurt herself
on purpose;86 uses alcohol or drugs;87 breaks rules, laws or doesn’t meet others’ expectations on
purpose;88 or thinks about suicide or feels she would be better off dead.89 She also responded that
she “Rarely” argues or speaks rudely to others90 or is sad or unhappy.91 In addition, when asked

74

AR 4027.
AR 4028.
76
AR 4031–32.
77
AR 4033.
78
AR 4035.
79
AR 4031.
80
AR 4034.
81
AR 4036–37.
82
AR 4021.
83
AR 4022, 4024.
84
AR 4023.
85
AR 4025.
86
Id.
87
Id.
88
AR 4027.
89
AR 4030.
90
AR 4021.
91
AR 4026.
75

how often she had been bothered by the following problems in the past two weeks, F.R.
responded “Not at all” with respect to having little interest or pleasure in doing things or having
thoughts that she would be better off dead or of hurting herself.92
On July 6, 2019, F.R.’s residential progress note stated that F.R. “seemed to be depressed
during the shift today. [F.R.] seemed to isolate herself and spent a lot of time alone during the
shift.”93 On July 9, 2019, F.R.’s individual therapy notes stated that F.R. “is showing great
positivity and self esteem right now . . . [and] returned from her home pass in high spirits and
adjusted quickly to being back. She said that she realized that she’d be able to see her mom more
frequently, and be home even more, so she’s lost a lot of anxiety she had that has been holding
her back.”94 The same individual therapy notes stated that F.R. “continues to report on the
following symptoms and behaviors demonstrating the continued need for RTC level of care.”95
On July 12, 2019, F.R.’s treatment summary noted that she is “[m]aking great progress
therapeutically,” is motivated, but also that her mother was concerned about bruising.96 On July
18, 2019, the treatment summary indicated that F.R.’s relationships with family are improving
and that her mood has been improving over the past several months, although F.R. notices each
month approximately five days of worsening mood during “beginning of her menses which is
consistent monthly.”97
On August 1, 2019, the treatment summary indicated that F.R. suffered from body image
issues leading to some restriction, as well as irritability with peers and decreased motivation and

92

AR 4036–37.
AR 3339.
94
AR 3980.
95
Id.
96
AR 3536.
97
Id.
93

hopelessness.98 F.R. also denied suicidal ideation or self-harm ideation and indicated that
intrusive thoughts were “not really” present.99 On September 6, 2019, the treatment summary
stated that F.R.’s “OCD themes [were] changing (body image),” “some restricting recently”
positive staff notes (generally), irritable, performing well in school, “bursts” of motivation, and
no suicidal ideation now but “occasional bursts” without intent or plan.100
On October 11, 2019, the treatment summary stated that F.R. had been working well with
peers despite some “chaos in the house,” “F.R. was motivated in program,” and that she was
“overall doing well.”101 It also indicated that F.R.’s transition/discharge would likely occur in
December.102 On November 13, 2019, the treatment summary stated that F.R. had just returned
from her longest home pass and “there were some issues that arose,” she had been feeling “sick”
for the past few weeks, suffered from some “anxiety moments” associated with feeling
physically “sick,” and that F.R. “might not discharge until January” instead of December.103 On
December 13, 2019, the treatment summary referenced positive staff notes, some “social
anxiety,” and some “anticipatory anxiety.”104 On January 24, 2020, F.R. was discharged from
New Haven.105

98

Id.
Id.
100
Id.
101
Id.
102
Id.
103
Id.
104
AR 3537.
105
AR 3537, 3555.
99

First Denial of Benefits
The court now turns to F.R.’s claims processing interactions with Cigna, who acted as the
claims administrator as of July 1, 2019.106 In a letter dated August 2, 2019, Cigna denied
payment for F.R.’s treatment from July 1, 2019 to January 1, 2020.107 The letter stated that
Cigna108 received a coverage request for F.R.’s stay at New Haven on July 17, 2019 and “Based
upon the available clinical information, your symptoms did not meet [] Behavioral Health
Medical Necessity Criteria for continued stay at Residential Mental Health Treatment for
Children and Adolescents level of care from 07/01/2019 - 01/01/2020.”109 In explaining the
rationale for the decision, the letter stated the following:
There was no current risk of harm to yourself or others. You did not demonstrate
a need for 24 hour/day monitoring and active treatment. Your family is involved
in treatment. From the available clinical evidence, you could receive psychiatric
treatment in a less restrictive setting. Less restrictive levels of care were
available.110
C.J. Appeals Cigna’s Denial of Coverage from July 1, 2019 Forward111
On January 16, 2020, F.R.’s mother, C.J., submitted a level one appeal of the August 2,
2019 decision.112 She argued that Cigna wrongly concluded that F.R.’s treatment at New Haven
was not medically necessary.113 In doing so, she points to F.R.’s diagnoses of Major Depressive
Disorder, OCD, and Generalized Anxiety Disorder; a history of cutting herself and suicidal

106

From February 15, 2019 to June 30, 2019, F.R.’s Plan was administered by United, who is no longer a
Defendant. Compl. ¶ 6; ECF No. 57. Thus, only the period beginning July 1, 2019 is at issue.
107
AR 4119–21.
108
The review was performed by Cigna’s Peer Reviewer, Mohsin Qayyum, M.D., a board-certified psychiatrist. AR
4119.
109
Id.
110
Id.
111
C.J. clarified that F.R.’s coverage should last until her future discharge date instead of January 1, 2020. AR 80.
112
AR 77–3515.
113
AR 78.

ideation, especially following her dad’s suicide in November 2018; and that none of F.R.’s
extensive past treatments have resolved her issues.114 The appeal also contained extensive
medical documentation from hospitals, doctors, teachers, and therapists to support her
arguments.115 Included among this documentation was, inter alia, New Haven’s medical records
from February 15, 2019 to January 8, 2020,116 discussed supra, and three letters of medical
necessity from Danella Hafeman, M.D., dated April 30, 2019; Marian Allen, RN, MSN, dated
May 7, 2019; and Lisa DeCarolis, LSW and Valerie Watson, dated May 22, 2019.117
In addition to the medical necessity argument, C.J. claimed that Cigna misunderstood the
level of care and type of treatment that RTCs render.118 In support, she cited Cigna’s Residential
Treatment Guidelines and argued that because they do not include any requirement that F.R. be a
“current risk of harm to [her]self or others,” the denial rationale does not correlate with the
guidelines and instead, is more appropriate for acute inpatient services.119
Finally, C.J. contended that Cigna violated the Parity Act because unlike for mental
health services, “Cigna has not developed any clinical guidelines for reviewing skilled nursing
facility or subacute rehabilitation facility services” and therefore “appears to impose a[] [nonquantitative treatment limitation] that only applies to behavioral health treatment.”120

114

AR 80–85.
AR 137–3372.
116
AR 910–3372.
117
AR 903–09.
118
AR 78.
119
AR 109.
120
AR 116.
115

Second Denial of Benefits
In a letter dated February 10, 2020, Cigna121 upheld its original decision to deny coverage
of F.R.’s stay at New Haven.122 The denial letter stated that:
Based upon the available clinical information received initially and with this
appeal, your symptoms did not meet Behavioral Health Medical Necessity
Criteria for continued stay at the Residential Mental Health Treatment for
Children and Adolescents level of care from 07/01/2019-07/01/2020 as the
treatment provided has led to sufficient improvement in the moderate to severe
symptoms and/or behaviors that led to this admission so that you could be safely
and effectively treated at a less restrictive level of care. The clinical information
described the individual as being in behavioral control, presenting with a stable
mood, actively engaging in programming and cooperative. The individual went on
home passes and demonstrated their ability to maintain safety in this outpatient
setting on multiple occasions. The clinical information provided indicated that the
individual had not developed new symptoms and/or behaviors that required this
intensity of service for safe and effective treatment. Less restrictive levels of care
were available for safe and effective treatment.123
Procedural Posture
Plaintiffs filed their Complaint on February 14, 2022.124 Cigna and the Plan filed their
Answers on May 31, 2022 and June 6, 2022, respectively.125 In February 2024, the parties filed
cross Motions for Summary Judgment, which were fully briefed on April 29, 2024.126
STANDARD
Under Federal Rule of Civil Procedure 56, summary judgment must be granted “if the
movant shows that there is no genuine dispute as to any material fact and the movant is entitled

121

The decision was made by Russell Sheffer, MD, a board-certified psychiatrist. AR 3517.
AR 3516–18.
123
AR 3517.
124
Compl., ECF No. 2.
125
ECF Nos. 18, 22.
126
Defs.’ MSJ; Pls.’ MSJ; Defs.’ Reply in Further Supp. of Their MSJ (“Defs.’ MSJ Reply”), ECF No. 83, filed on
April 29, 2024; Pls.’ Reply in Further Supp. of Their MSJ (“Pls. MSJ Reply”), ECF No. 82, filed on April 29, 2024.
122

to judgment as a matter of law.”127 “Where, as here, the parties in an ERISA case both moved for
summary judgment . . . , summary judgment is merely a vehicle for deciding the case; 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.”128
DISCUSSION
The parties move for summary judgment on Plaintiffs’ two claims: Cigna’s denial of
benefits and an alleged MHPAEA violation. The court considers each in turn.
I.

Denial of Benefits Claim
ERISA “sets minimum standards for employer-sponsored health plans[.]”129 Congress

enacted the regulations “to promote the interests of employees and their beneficiaries in
employee benefit plans, and to protect contractually defined benefits.”130 For this reason,
“ERISA represents a careful balancing between ensuring fair and prompt enforcement of rights
under a plan and the encouragement of the creation of such plans.”131 The court first addresses
the proper standard of review.
A.

Standard of Review

Under 29 U.S.C. § 1132(a)(1)(b), a civil action may be brought by an insurance plan
participant to recover benefits under the terms of the plan. The Supreme Court has held that “a
denial of benefits challenged under [ERISA] must be reviewed under a de novo standard unless

127

Fed. R. Civ. P. 56(a).
Carlile v. Reliance Standard Life Ins., 988 F.3d 1217, 1221 (10th Cir. 2021) (cleaned up) (quoting LaAsmar v.
Phelps Dodge Corp. Life, Accidental Death & Dismemberment & Dependent Life Ins. Plan, 605 F.3d 789, 796 (10th
Cir. 2010)).
129
D.K. v. United Behav. Health, 67 F.4th 1224, 1236 (10th Cir. 2023).
130
Black & Decker Disability Plan v. Nord, 538 U.S. 822, 830 (2003) (citation omitted).
131
Matney v. Barrick Gold of N. Am., 80 F.4th 1136, 1145 (10th Cir. 2023) (internal quotation marks omitted)
(quoting Conkright v. Frommert, 559 U.S. 506, 517 (2010)).
128

the benefit plan gives the administrator or fiduciary discretionary authority to determine
eligibility for benefits or to construe the terms of the plan.”132
Where the plan administrator has discretionary authority, courts “employ a deferential
standard of review, asking only whether the denial of benefits was arbitrary and capricious.”133
Defendants carry the burden to demonstrate that the arbitrary and capricious standard applies.134
Courts will uphold the administrator’s determination “so long as it was made on a reasoned basis
and supported by substantial evidence.”135 “Substantial evidence requires more than a scintilla
but less than a preponderance.”136 Substantial evidence is “‘such evidence that a reasonable mind
might accept as adequate to support a conclusion reached by the decision-maker.’”137
“In determining whether the evidence in support of the administrator’s decision is
substantial, [courts] must take into account whatever in the record fairly detracts from its
weight.”138 Plan administrators may not arbitrarily refuse to engage with a claimant’s reliable
evidence—including the opinions of a treating physician.139 However, “a benefits decision can
be reasonable even when the insurer receives evidence contrary to the evidence it relies upon.”140
For example, where an administrator “credits reliable evidence that conflicts with a treating
physician’s evaluation,” courts may not require that plan administrators provide an explanation

132

Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); Foster v. PPG, Inc., 683 F.3d 1223, 1231
(10th Cir. 2012).
133
L.D. v. UnitedHealthcare Ins., 684 F. Supp. 3d 1177, 1195 (D. Utah July 28, 2023) (quoting LaAsmar, 605 F.3d
at 796).
134
M.S. v. Premera Blue Cross, 553 F. Supp. 3d 1000, 1019 (D. Utah 2021).
135
Van Steen v. Life Ins. Co. of N. Am., 878 F.3d 994, 997 (10th Cir. 2018).
136
Graham v. Hartford Life & Acc. Ins. Co., 589 F.3d 1345, 1358 (10th Cir. 2009).
137
David P. v. United Healthcare Ins. Co., 77 F.4th 1293, 1308 (10th Cir. 2023) (quoting Sandoval v. Aetna Life &
Cas. Ins. Co., 967 F.2d 377, 382 (10th Cir. 1992).
138
David P., 77 F.4th at 1308.
139
Black & Decker, 538 U.S. at 834.
140
David P., 77 F.4th at 1308.

as to why the administrator favored that evidence over the physician’s evaluation.141 However,
an administrator also may not arbitrarily refuse to credit evidence that may confirm a
beneficiary’s theory of entitlement.142 Thus, if a treating physician’s evaluation confirms a
claimant’s theory of entitlement, an administrator may not arbitrarily refuse to “engage and
address” such an evaluation.143 “[R]eviewers cannot shut their eyes” to reliable evidence and
ignore it.144
Arbitrary and capricious review considers whether the decision had a reasoned basis that
is supported by substantial evidence.145 This includes whether the decision is “consistent with
any prior interpretations by the plan administrator, is reasonable in light of any external
standards, and is consistent with the purposes of the plan.”146 “Consistent with the purposes of
the plan requirements means that a plan administrator acts arbitrarily and capriciously if the
administrator ‘fails to consistently apply the terms of an ERISA plan’ or provides ‘an
interpretation inconsistent with the plan’s unambiguous language.’”147
The Plan “delegates to Cigna the discretionary authority to interpret and apply Plan terms
and to make factual determinations in connection with its review of claims under the Plan,”
including the determination of whether a person is entitled to benefits under the Plan.148
Therefore, the arbitrary and capricious standard of review applies.

141

Black & Decker, 583 U.S. at 834. “This conclusion does not create any blanket requirement that a health plan
administrator considering a claim for health care benefits must seek out all treating care givers’ opinions found in a
claimant’s medical records and explain whether or not the plan administrator agrees with each of those opinions and
why.” David P., 77 4th at 1312.
142
D.K., 67 F.4th at 1237 (quoting Gaither v. Aetna Life Ins. Co., 394 F.3d 792, 807 (10th Cir. 2004)).
143
Id. (citing Black & Decker, 583 U.S. at 834).
144
David P. 77 F.4th at 131011.
145
D.K., 67 F.4th at 1236.
146
Id.
147
Id. (quoting Tracy O. v. Anthem Blue Cross & Life Health Ins., 807 Fed. Appx. 845, 854 (10th Cir. 2020).
148
AR 4133.

B.

ERISA’s Claim Processing Requirements

ERISA sets minimum requirements for employer-sponsored health plans, which may be
administered by a third party.149 “Administrators, like [Cigna], are analogous to trustees of
common-law trusts and their benefit determinations constitute fiduciary acts.”150 Thus,
administrators owe a special duty of loyalty to plan beneficiaries in determining benefit
eligibility.151
“ERISA promotes the interests of plan participants and beneficiaries and contractually
defined benefits ‘in part by regulating the manner in which plans process benefits claims.’”152
These standards constitute the minimum requirements for a plan’s claims-processing
procedure.153 The procedure, set forth in 29 U.S.C. § 1133 and in related implementing
regulations, require “a meaningful dialogue between ERISA plan administrators and their
beneficiaries.”154 When administrators issue denial letters, they need to explain in clear language
the reason(s) for their decision.155 The Tenth Circuit has held that “the administrator must
include its reasons for denying coverage in the four corners of the denial letter” because denial
letters “play a particular role in ensuring full and fair review.”156 The purposes of ERISA’s claim
processing requirements “are undermined where plan administrators have available sufficient
information to assert a basis for denial of benefits but choose to hold that basis in reserve rather

149

29 U.S.C. § 1001; D.K., 67 F.4th at 1236.
D.K., 67 F.4th at 1236.
151
Id. (quoting Metro. Life Ins. V. Glenn, 554 U.S. 105, 111 (2008)).
152
David P., 77 F.4th at 1299 (quoting Black & Decker, 538 U.S. at 830).
153
Id.
154
Id. at 1300.
155
D.K., 67 F.4th at 1239 (quoting Booton v. Lockheed Medical Benefit Plan, 110 F.3d 1461, 1463 (9th Cir. 1997)).
156
Ian C. v. UnitedHealthcare Ins. Co., 87 F.4th 1207, 1219 (10th Cir. 2023).
150

than communicate it to the beneficiary.”157 Thus, when an administrator holds in reserve a basis
for providing benefits, the administrator prevents a full and meaningful dialogue.158
“[I]f the plan administrators believe that more information is needed to make a reasoned
decision, they must [clearly] ask for it,” explaining why the information is needed.159 If they
deny benefits based on the text of the plan, they must cite to the specific provisions of the
plan.160 And if plan administrators deny benefits based on their scientific or clinical judgment of
the claimant’s circumstances, they must explain their reasoning as applied to the terms of the
plan.161
Relatedly, ERISA sets out minimum requirements for the appeals procedure for members
to challenge initial denial decisions.162 A plan’s review procedures must “‘afford a reasonable
opportunity to any participant whose claim for benefits has been denied [to receive] a full and
fair review . . . .’”163 ERISA’s “full and fair review” creates a procedure by which claimants
receive letters “knowing what evidence the decision-maker relied upon, having an opportunity to
address the accuracy and reliability of the evidence, and . . . having the decision-maker consider
the evidence presented by both parties to reaching and rendering [its] decision.”164 This includes
providing claimants an “opportunity to submit written comments, documents, records, and other
information relating to the claim for benefits” as well as conducting a “review that takes into

157

David P., 77 F.4th at 1313.
Id.
159
Id. at 1300.
160
David P., 77 F.4th at 1299 (citing 29 C.F.R. § 2560.503-1(g)(1)).
161
Id.
162
29 U.S.C. § 1132(2).
163
D.K., 67 F.4th at 1236 (quoting 29 U.S.C. § 1133).
164
Id. (quoting Sage v. Automation, Inc. Pension Plan & Tr., 845 F.2d 885, 893–94 (10th Cir. 1988)).
158

account all . . . information submitted by the claimant relating to the claim.”165 “[A]dministrator
statements may not be conclusory and any health conclusions must be backed up with reasoning
and citations to the record.”166
The court turns to Plaintiffs’ arguments regarding Cigna’s alleged improper denial of
benefits in violation of ERISA. Plaintiffs seek the recovery of benefits from July 1, 2019 through
January 24, 2020.
C.

Plaintiffs’ Benefits Determination Arguments

Plaintiffs argue that Cigna failed to provide a “full and fair review” and engage in a
meaningful dialogue in its appeals process.167 Specifically, they allege that Cigna’s claims
processing was inadequate by failing to engage with F.R.’s medical history and treatment notes,
as well as her letters of medical necessity.168 Instead, according to Plaintiffs, Cigna’s letters of
denial were limited to conclusory statements without citation to the record.169 Plaintiffs also
argue that in addition to Cigna’s procedural deficiencies, the record clearly demonstrates that
F.R.’s treatment was medically necessary, such that F.R. is entitled to an award of benefits
instead of remand.170 The court treats each argument in order.

165

David P., 77 F.4th at 1299 (quoting 29 C.F.R. § 2560.503-1(h)(2)(ii), (iv)).
D.K., 67 F.4th at 1242 (citing McMillan v. AT&T Umbrella Benefit Plan No. 1, 746 F. App’x 697, 705–06 (10th
Cir. 2018) (unpublished)); see David P., 77 F.4th at 1312.
167
Pls.’ MSJ 17–22.
168
Id.
169
Id.
170
Id. at 22–27.
166

1.

Failure to Address F.R.’s Medical History and Treatment Notes

Plaintiffs argue that Cigna’s benefits denial letters concerning F.R.’s treatment at New
Haven repeatedly made conclusory statements in contradiction to F.R.’s medical history and
treatment notes.171
The initial denial letter dated August 2, 2019 concluded—without any explanation or
reference to the record—that
There was no current risk of harm to yourself or others. You did not demonstrate
a need for 24 hour/day monitoring and active treatment. Your family is involved
in treatment. From the available clinical evidence, you could receive psychiatric
treatment in a less restrictive setting. Less restrictive levels of care were
available.172
This denial letter was conclusory and did not specifically reference any of F.R.’s medical
records173 dated from July 1, 2019 to July 11, 2019 that it purported to review.174 Additionally,
the reviewer’s reference to family being involved in treatment as part of the denial reason is odd,
given that Cigna’s Residential Treatment Guidelines require that family be involved to the best
of their ability in the treatment and discharge planning process.175
Moreover, Cigna made these statements despite available clinical information in early
July 2019, where, among other evidence, a treating therapist specifically concluded that F.R.’s
“symptoms and behaviors demonstrat[e] the continued need for RTC level of care.176 Cigna did

171

Pls.’ MSJ 13, 20–21, 26–27.
AR 4119–21.
173
See D.K., 67 F.4th at 1242 (“[Plan administrator’s] failure to cite any facts in the medical record constituted
conclusory reasoning and thus [Plan administrator] acted arbitrarily and capriciously.”).
174
The denial letter did not indicate which specific records Cigna reviewed other than “available clinical
information.” AR 4119; see also AR 3958 (New Haven attaching F.R.’s medical records from July 1, 2019 to July
11, 2019).
175
AR 4226–27.
176
AR 3341, 3980, 4018.
172

not have to defer to the opinion of F.R.’s treating therapist at New Haven, however, it could not
arbitrarily refuse to consider it.177
Cigna’s second denial letter, dated February 10, 2020,178 marked an improvement,
although it still suffered from many of the same defects as its prior letter:
Based upon the available clinical information received initially and with this
appeal, your symptoms did not meet Behavioral Health Medical Necessity
Criteria for continued stay at the Residential Mental Health Treatment for
Children and Adolescents level of care from 07/01/2019-07/01/2020 as the
treatment provided has led to sufficient improvement in the moderate to
severe symptoms and/or behaviors that led to this admission so that you
could be safely and effectively treated at a less restrictive level of care. The
clinical information described the individual as being in behavioral control,
presenting with a stable mood, actively engaging in programming and
cooperative. The individual went on home passes and demonstrated their
ability to maintain safety in this outpatient setting on multiple occasions. The
clinical information provided indicated that the individual had not developed
new symptoms and/or behaviors that required this intensity of service for
safe and effective treatment. Less restrictive levels of care were available for
safe and effective treatment. (Emphasis added).179
Defendants argue that the bolded portions of the letter show that Cigna’s reviewer did not
“fail to respond” because the denial letter “specifically references the clinical information
provided,” such as F.R. being in behavioral control, presenting with a stable mood, actively
engaging in programming and cooperative, going on successful home passes, demonstrating an
ability to maintain safety, and developing no new symptoms and/or behaviors requiring this
intensity of service.180
Although the letter does mention some specifics—primarily factual conclusions with no
additional explanation—ERISA requires that an administrator’s explanation of a clinical or
177

D.K., 67 F.4th at 1237.
AR 3516–18.
179
AR 3517.
180
Defs.’ MSJ Reply 3–6.
178

medical judgment “may not be conclusory and any health conclusions must be backed up with
reasoning and citations to the record.”181 The explanation must also “apply[] the terms of the
plan to the claimant’s medical circumstances.”182
On this record, Cigna’s denial letters do not meet these minimum standards. After
reviewing the denial letter, it still is unclear which “clinical information” Cigna used in making
the determination. Granted, Cigna’s reviewer stated earlier in the letter that he examined
“available clinical information received initially and with this appeal.”183 However, this merely
provides in conclusory fashion what records were examined—not which records supported
Cigna’s decision. More importantly, and critical to the court’s determination here—Cigna failed
to grapple with the specific facts that could have justified awarding benefits just as inadequately
as it failed to address the medical opinions that may have justified the denial of benefits. The
beneficiary and the court are left with no way of discerning the degree to which Cigna engaged
with the record.
Specifically, the denial letter does not reference policy terms, does not specifically
respond to any of the arguments F.R. made in her appeal, and fails to cite with specificity any of
F.R.’s medical records, nor explain how those medical records applied to Cigna’s denial
rationale.184 For example, nowhere in the denial letter does Cigna’s reviewer respond to the
opinion of F.R.’s treating therapist, who stated on multiple occasions in July 2019, August 2019,
September 2019, October 2019, and November 2019 that F.R.’s “symptoms and behaviors

181

David P., 77 F.4th at 1312 (citing 29 C.F.R. § 2560.503-1(g)(1)(v)(B)).
Id.
183
AR 3517.
184
AR 3516–18.
182

demonstrat[e] the continued need for RTC level of care.”185 Nor does Cigna’s reviewer respond
to medical records that conflict with F.R. “presenting with a stable mood,” such as treatment
summaries that indicated that F.R. suffered from “[b]ody image issues leading to some
restriction,” hopelessness, and “occasional bursts” of suicidal ideation without intent or plan.186
Additionally, Cigna mentioned positive home pass experiences without referencing the “issues
that arose” and suffering from some “anxiety moments” on her November 2019 home pass,
which resulted in F.R.’s discharge being pushed back from December to January 2019.187 In
short, Defendants failed to engage with the record.
Defendants attempt to distinguish the Tenth Circuit’s recent decisions in D.K. v. United
Behavioral Health,188 David P. v. United Healthcare Insurance Company,189 and Ian C. v.
UnitedHealthcare Insurance Company.190 First, Defendants argue that D.K. is “inapposite
because the fact-specific conclusions in D.K. regarding the administrative review process and
procedural errors in that case do not support a finding of abuse of discretion here”—namely that
the claim administrators in D.K. erroneously thought the plan excluded the type of treatment at
issue.191 But as Plaintiffs point out, “Cigna fails to explain why D.K.’s central holding does not
apply to the denial letters in this case.”192 As noted in Anne A. v. United Healthcare Ins. Co.,193
But the facts that distinguish this case from D.K. subtract nothing from its central
holding: ERISA requires insurers to engage in a full and meaningful prelitigation
dialogue regarding the denial of benefits, which must include actual explanation
185

AR 1576, 2552, 2621, 2649, 2735, 2786, 2839, 2919, 2950, 3341, 3348, 3353, 3355, 3367, 3371.
AR 3536.
187
AR 3536.
188
67 F.4th 1224 (10th Cir. 2023).
189
77 F.4th 1293 (10th Cir. 2023).
190
87 F.4th 1207 (10th Cir. 2023); Defs.’ MSJ 21–23.
191
Defs.’ MSJ 22.
192
Pls.’ Opp. to Defs.’ MSJ 25, ECF No. 79, filed on April 3, 2024.
193
No. 2:20-cv-00814-JNP-DAO, 2024 WL 1307168 (D. Utah Mar. 26, 2024).
186

of benefits denials that grapple with contrary evidence presented to the claims
administrator, including treating physicians’ opinions. D.K., 67 F.4th at 1241. In
this case, Defendants plainly failed to do so.194
Next, Defendants attempt to distinguish David P. and Ian C.195 Defendants point out that
in those cases, “the claim administrator did not address claimant’s substance abuse treatment in
the denial letters even though ‘it was clear from the record . . . that [the RTCs] were each treating
L.P. for substance abuse, in addition to providing mental health treatment.’”196 In contrast,
Defendants argue that in this case, “there is no evidence of any substance abuse concerns or
treatment with respect to F.R.”197
Again, this argument presents an unreasonably narrow view of the Tenth Circuit’s
holdings and simply reflects a difference in the specific facts. This difference does not subtract
from the Tenth Circuit’s reiteration that although a plan administrator “is not required to defer to
the opinions of a treating physician,” its reviewers cannot “arbitrarily refuse to credit such
opinions” nor can they “shut their eyes to readily available information . . . [that may] confirm
the beneficiary's theory of entitlement.”198
2.

Failure to Engage with Medical Necessity Opinion Letters

In addition to F.R.’s medical history and records from her stay at New Haven, C.J.
included in her appeal three letters of “medical necessity.”199 First, C.J. submitted a letter dated
April 30, 2019 from Danella Hafeman, M.D., who treated F.R. from December 19, 2017 through

194

Id. at *7 n.9
Defs.’ MSJ 23.
196
Id.
197
Id.
198
David P., 77 F.4th at 1310–11 (quoting D.K., 67 F.4th at 1237); Ian C., 87 F.4th at 1220.
199
AR 903–09.
195

January 16, 2019.200 Dr. Hafeman pointed to F.R.’s past diagnoses and treatment in IOP before
opining that F.R. “required an intense level of care beyond IOP that would provide the length of
time needed to clinically support her recovery.”201 Second, C.J. submitted a letter dated May 7,
2019 from a therapeutic/education consultant the family retained.202 The consultant stated that
she “observed a young woman with severe, worsening depression who was immobilized by
anxiety and OCD, unable to attend school or leave home and prone to angry physical
outbursts.”203 She recommended F.R. receive treatment at New Haven.204 Finally, C.J. submitted
a letter dated May 22, 2019 from Lisa DeCarolis, a licensed social worker, and Valerie Watson, a
special education teacher, both from the Pittsburgh Creative and Performing Arts school, where
F.R. was a student.205 After discussing some of F.R.’s past treatment and the detrimental effect of
her symptoms on her ability to perform in school, the letter concluded that the writers were
“hopeful that with residential treatment she will get the 24 hour, therapeutic care that will allow
her to develop the skills that she will need to manage significant mental health issues and be able
to function as a student in our school again in the future.”206
Defendants make an array of arguments as to why these letters are not persuasive.207
First, they point out that all of these letters are dated over a month prior to July 1, 2019, the
beginning of the coverage period in question, and some of the treatments and observations of

200

AR 904.
Id.
202
AR 906.
203
Id.
204
AR 907.
205
AR 909.
206
Id.
207
Defs.’ MSJ 18–19.
201

symptoms were provided months earlier.208 Accordingly, the writers “could not have reviewed
clinical information or opined on F.R.’s current needs or level of care as of July 1, 2019.”209
Second, Dr. Hafeman did not specifically opine that F.R. required an RTC level of care, given
that partial hospitalization is an “intense level of care beyond IOP.”210 Third, Ms. Allen never
treated F.R. and stated that F.R. was “progressing” at New Haven nearly two months prior to the
treatment period in question.211 And fourth, Ms. DeCarolis, LSW, and Ms. Watson are nonmedical professionals and are thus not qualified to render an opinion on “medical necessity.”212
Some of these arguments might well have merit. Defendants’ failing, however, is that
they provided none of these reasons in Cigna’s second denial letter, which does not reference or
discuss any of the letters.213 Even if Defendants dismissed the letters from school personnel and
the family’s consultant as unhelpful to their medical necessity determination, the letter from Dr.
Hafeman is a treater letter. Defendants did not necessarily have to defer to it, but they did have to
engage with it. ERISA’s procedural safeguards require “a meaningful dialogue between ERISA
plan administrators and their beneficiaries.”214 Yet, Cigna’s February 10, 2020 denial letter failed
to engage with even the treater’s letter, instead simply reiterating without explanation or citation
to the record that “[l]ess restrictive levels of care were available for safe and effective
treatment.”215 “It cannot be that the depth of an administrator’s engagement with medical opinion

208

Id.
Id. at 19.
210
Id. at 18.
211
Id. at 18–19.
212
Id. at 19 n.3.
213
See AR 3517.
214
David P., 77 F.4th at 1300.
215
AR 3517.
209

would be revealed only when the record is presented for litigation.”216 Cigna’s claims processing
here was not a “full and fair review” of F.R.’s record, nor did Cigna provide F.R.’s parents with
a “meaningful dialogue.” Accordingly, Defendants’ denial of coverage was arbitrary and
capricious.
D.

Remand for Further Consideration

Having determined that Cigna acted arbitrarily and capriciously when it failed to comply
with ERISA’s claims processing requirements, the court must decide whether to remand for the
plan administrator’s “renewed evaluation of the claimant’s case” or to award benefits.217 This
decision “hinges on the nature of the flaws in the administrator’s decision.”218 Typically,
“remand is appropriate if the administrator failed to make adequate factual findings or failed to
adequately explain the grounds for the decision.”219 “But if the evidence in the record clearly
shows that the claimant is entitled to benefits, an order awarding such benefits is appropriate.”220
If the record contains both evidence supporting Plaintiffs’ claims for benefits and evidence
supporting the denial of benefits, it cannot be said that the record “clearly shows” that the
claimant is entitled to benefits.221
If benefits are not awarded, remand is proper. A remand, however, “does not provide the
plan administrator the opportunity to reevaluate a claim based on a rationale not raised in the

216

D.K., 67 F.4th at 1241.
Weber v. GE Grp. Life Assur. Co., 541 F.3d 1002, 1015 (10th Cir. 2008) (quoting Flinders, 491 F.3d at 1193).
218
Carlile v. Reliance Standard Life Ins., 988 F.3d 1217, 1229 (10th Cir. 2021).
219
David P., 77 F.4th at 1315 (cleaned up); see id. (citing Spradley v. Owens-Illinois Hourly Emps. Welfare Ben.
Plan, 686 F.3d 1135, 1142 (10th Cir. 2012)) (“[R]emand is more appropriate where plan administrator failed to
make adequate factual findings or failed to explain adequately the grounds for its decision to deny benefits, but not
if the administrator instead gave reasons that were incorrect”); Buffonge v. Prudential Ins. Co. of Am., 426 F.3d 20,
31 (1st Cir. 2005) (concluding remand as the proper remedy when the “problem is with the integrity of [the plan
administrator]’s decision-making process”).
220
David P., 77 F.4th at 1315 (cleaned up).
221
David P., 77 F.4th at 1314 n.17.
217

administrative record, and not previously conveyed to plaintiffs.”222 Thus, in evaluating whether
Cigna’s interpretation of the Plan was “reasonable and in good faith,” the court reviews only
those rationales that are in the administrative record and conveyed to Plaintiffs. The court now
turns to whether the “record clearly shows” that coverage is warranted from July 1, 2019 to
January 24, 2020.
Here, Cigna did not provide F.R. a “full and fair review.”223 It rejected, without
meaningful explanation or record support, Plaintiffs’ arguments that F.R.’s treatment was
medically necessary based on, for example, F.R.’s prior medical history, her medical necessity
letters, and her New Haven medical records. But the court cannot conclude that the “‘record
clearly shows’ Plaintiffs are entitled to benefits, nor can [it] say that Plaintiffs are clearly not
entitled to the claimed benefits.”224
For example, F.R.’s treatment notes between July 1, 2019 and January 8, 2020 illustrate
positive progress, such as F.R. “showing great positivity and self esteem right now,” losing “a lot
of anxiety she had that has been holding her back,” and “[m]aking great progress
therapeutically.”225 But her therapist also opined that F.R.’s “symptoms and behaviors
demonstrat[e] the continued need for RTC level of care”226 and that F.R. has “no [suicidal
ideation] now but [has] ‘occasional bursts’ without intent or plan.”227 Further, as discussed
supra, F.R.’s July 3, 2019 self-questionnaire displayed mixed results.228

222

David P., 77 F.4th at 1315.
29 U.S.C. § 1133(2).
224
David P., 77 F.4th at 1315.
225
AR 3980, 3536.
226
AR 1576, 2552, 2621, 2649, 2735, 2786, 2839, 2919, 2950, 3341, 3348, 3353, 3355, 3367, 3371.
227
AR 3536.
228
AR 4020–35.
223

Remand is thus the proper remedy. The court declines to award benefits for F.R.’s stay at
New Haven because, having reviewed the evidence, the court cannot say the “record clearly
shows” coverage is warranted.
II.

MHPAEA (Parity Act) Claims
Plaintiffs additionally claim that Defendants violated MHPAEA by misapplying medical

necessity requirements in favor of Cigna’s own guidelines in its denial letters and having
additional requirements for mental health coverage that do not apply in comparable medical or
surgical care.229 “Congress enacted [MHPAEA] to end discrimination in the provision of
insurance coverage for mental health and substance use disorders as compared to coverage for
medical and surgical conditions in employer-sponsored group health plans.”230 A “comparison of
treatment limitations under MHPAEA must be between mental health/substance abuse and
medical/surgical care ‘in the same classification.’”231 For example, “if a plan or issuer classifies
care in skilled nursing facilities or rehabilitation hospitals as inpatient benefits, then the plan or
issuer must likewise treat any covered care in residential treatment facilities for mental health or
substance user disorders as an inpatient benefit.”232 But the plans need not have identical
coverage criteria so long as the application of nonquantitative treatment limitation to mental
health or substance use disorder benefits in the classification are comparable to, and are applied

229

Pls.’ MSJ 29–35.
Michael D. v. Anthem Health Plans of Ky., Inc., 369 F. Supp. 3d 1159, 1174 (D. Utah 2019) (quoting Am.
Psychiatric Ass'n v. Anthem Health Plans, Inc., 821 F.3d 352, 356 (2d Cir. 2016)).
231
Peter M. v. Aetna Health & Life Ins. Co., 554 F. Supp. 3d 1216, 1226–27 (D. Utah 2021) (quoting 29 C.F.R.
§ 2590.712(c)(4)(i), 2(ii)(A)).
232
Robert B. v. Premera Blue Cross, 701 F. Supp. 3d 1153, 1182 (D. Utah 2023).
230

no more stringently than, those used in applying the limitation with respect to medical/surgical
benefits.233
As discussed in Theo M. v. Beacon Health Options, 631 F. Supp. 3d 1087 (D. Utah
2022), because the court has concluded that remand is the appropriate remedy for the denial of
Plaintiffs’ benefits, the MHPAEA claim is moot.234 Similar to Theo M., Plaintiffs here argue that
“F.R. may well need to seek benefits from the Plan in the future,”235 despite Defendants pointing
out that they no longer employ the guidelines at issue in this case.236 But the court cannot decide
the MHPAEA claim “on the possibility of a future denial of benefits.”237 Accordingly, the court
does not reach the issue of whether Defendants violated MHPAEA.
ORDER
Accordingly, the court GRANTS IN PART Plaintiffs’ motion and DENIES Defendants’
motions. The court REMANDS the benefits determination from July 1, 2019 to January 24, 2020
to Defendants for further review of Plaintiffs’ benefits claim consistent with this Memorandum
Decision and Order. The court does not address the parties’ cross-motions for summary
judgment on the MHPAEA claim because this order has rendered the issue moot.

233

Id. (citing 29 C.F.R. § 2590.712(c)(4)(i)).
Id. at 1110–11 (citing David P. v. United Healthcare Ins. Co., 564 F. Supp. 3d 1100, 1123 (D. Utah 2021), aff'd
in part, vacated in part, rev'd in part, 77 F.4th 1293 (10th Cir. 2023)); see also Michael D. v. Anthem Health Plans
of Kentucky, Inc., 369 F. Supp. 3d 1159, 1176 (D. Utah 2019) (declining to reach a ruling on the MHPAEA claim
after finding exclusion of benefits arbitrary and capricious).
235
Pls.’ MSJ 38.
236
Defs.’ MSJ 12 n.2.
237
M.A. v. United Healthcare Ins., No. 1:21-cv-00083-JNP-DBP, 2023 WL 6318091, at *10 (D. Utah Sept. 28,
2023) (citing Thomas v. Union Carbide Agricultural Products Co., 473 U.S. 568, 580–81 (1985)).
234

Signed September 24, 2024.
BY THE COURT
________________________________________
David Barlow
United States District Judge