Skip to main content

Kantor & Kantor’s health team recently scored another victory in a matter involving the denial of residential treatment.

In Doe v. Blue Cross Blue Shield of Illinois, No. CV-19-05044-PHX-SMB, __F.Supp.3d__, 2020 WL 5891723 (D. Ariz. Oct. 5, 2020), Jane Doe was a dependent beneficiary of an ERISA-governed health plan insured and administered by Defendant Blue Cross Blue Shield of Illinois (“BCBS”). Sadly, Ms. Doe struggled with anorexia nervosa, generalized anxiety disorder, major depressive disorder, and post-traumatic stress disorder resulting from a past of multiple sexual assaults. Due to her severe symptoms, including significant weight loss, suicidal ideation with a plan, eating disorder behaviors, panic attacks, and compulsive behaviors, Ms. Doe’s doctors recommended inpatient treatment. BCBS approved only a few weeks of inpatient treatment and then determined that she could be treated at the intensive outpatient care level. (There are five descending levels of care for mental health treatment: (1) inpatient care, (2) residential treatment, (3) partial hospitalization, (4) intensive outpatient, and (5) outpatient.)

Rather than accept this much lower level of care, Ms. Doe instead transferred to residential treatment at La Ventana Treatment Center. She remained there from March 16, 2017, to July 11, 2017 (First Period). Her symptoms worsened after July 11th and her treatment team recommended inpatient treatment, which BCBS approved. However, after August 15, 2017, Ms. Doe sought continued residential treatment and BCBS denied this level of care in favor of partial hospitalization. Despite the denial, Ms. Doe stayed in residential treatment from August 15 to August 21, 2017 (Second Period). Thereafter, she stepped down to the partial hospitalization level of care.

On de novo review, the court considered whether Ms. Doe’s two disputed periods of residential treatment were considered “medically necessary” under the health plan. Medical necessity under the plan refers to “generally accepted medical standards” which is not a defined term in the plan.

First, the court determined that the Milliman Care Guidelines (“MCG”) reflect a generally accepted medical standard based on many court decisions relying on the MCG to determine medical necessity. The court found that Plaintiff did not meet her burden in showing that the MCG is not a generally accepted medical standard. The court rejected Doe’s argument that BCBS should have used the American Psychological Association (“APA”) guidelines instead.

As noted by the court, “[u]nder the MCG ‘residential care’ is appropriate either when the patient requires a structured setting with around-the-clock care, or when the patient cannot participate or benefit from a lower level of care.” Applying the MCG, the court found that Doe met both standards of residential care for the First Period. She routinely refused food or consumed half of her meal plan, required structure and support to abate purging and restricting, experienced frequent episodes of disassociation and dysregulation, and experienced urges of self-harm and suicidal ideation which progressed to action. The court rejected BCBS’s effort to cherry-pick the record of instances where Doe had brief periods of doing better or complying with treatment. The court also found that BCBS seemingly ignored its guidelines. Because Doe required a structured setting with around-the-clock care and could not be appropriately managed in a lower level of care, the court granted Plaintiff’s motion for judgment as to the First Period.

However, concerning the Second Period, the court ruled in favor of BCBS. The court found that by the Second Period, Doe’s symptoms were more manageable and partial hospitalization was appropriate.

Lastly, the court noted the Defendant’s notice of the supplemental authority, wherein it informed the court of the recent decision in Doe v. Harvard Pilgrim Health Care, Inc., et al., __F.3d__, 2020 WL 5405367 (1st Cir., Sept. 9, 2020), was non-compliant with the rules because it included argument regarding the case. The court declined to consider Defendant’s additional argument. The court deferred consideration of Plaintiff’s entitlement to attorneys’ fees until Plaintiff files her motion and supporting documentation.

Jane Doe is represented by Kantor & Kantor partner, Elizabeth K. Green. Kantor & Kantor Insurance Advocate, Kathleen MacDonald, also assisted Ms. Doe during the pre-litigation appeals process.

If you or someone you know is suffering from an eating disorder and you are being denied benefits by your insurance provider, please call Kantor & Kantor for a free consultation or use our online contact form. We understand, and we can help.