M. v. United Healthcare Insurance

Background

J.M., a participant in the Credit Suisse Securities (USA) LLC Group Health Care Plan, is M.M.’s father. M.M. was an adolescent and a covered beneficiary under the plan during the relevant events. The plan is a self-funded employee welfare benefits plan governed by the Employee Retirement Income Security Act (ERISA). The plan required covered services to be medically necessary and excluded charges for confinement in a place primarily functioning as a school or place of rest.

M.M. received mental-health services at Elevations RTC from February 25 through May 24, 2019, and at Daniels Academy from May 26, 2019, through May 21, 2021. The defendants covered the first 18 days at Elevations but denied coverage for the remainder of that treatment and all of the Daniels Academy treatment. The denials were based on the conclusion that continued residential treatment was not medically necessary.

After several rounds of administrative appeals, the Benefits Committee issued a final denial on November 4, 2022. During the later appeals, the defendants used the Child & Adolescent Level of Care / Service Intensity Utilization System for Children and Adolescents Ages 6-18 (CASII) to evaluate the appropriate level of care. The parties then filed cross-motions for summary judgment, asking the court to decide the case based on the record and applicable law without a trial.

ERISA Claim

The plaintiffs sought recovery of benefits under ERISA. Because the plan gave the Benefits Committee discretionary authority to interpret the plan and determine benefit eligibility, the court reviewed the benefit denials under the arbitrary-and-capricious standard. Under that standard, a denial may be overturned only if it lacks a reasonable basis, is unsupported by substantial evidence, or is legally wrong. Substantial evidence means evidence that a reasonable person could accept as adequate to support the decision.

The court held that the defendants complied with ERISA’s claims-procedure requirements. The final denial and earlier appeal decisions stated that the residential treatment was not medically necessary, cited the plan’s medical-necessity requirement, and explained the clinical reasoning. The decisions applied CASII to M.M.’s diagnoses and circumstances, concluded that he did not require around-the-clock residential treatment, and explained that less intensive outpatient care could address his needs. The court also stated that the defendants were not required to defer to the opinions of M.M.’s treating professionals.

Elevations Treatment

The court found substantial evidence supporting the denial of coverage for Elevations from March 15 through May 24, 2019. Dr. Randall Solomon evaluated the six CASII dimensions and calculated a score of 18, which supported intensive outpatient services rather than residential care. He noted that M.M. participated in activities, had no safety issues requiring 24-hour supervision, was responding well to treatment, and had conditions that could be treated through outpatient psychotherapy.

An independent review likewise found no acute symptoms requiring residential treatment and concluded that similar therapy and medication management could be provided at a lower level of care. The court rejected the plaintiffs’ arguments that M.M. met CASII’s criteria for serious risk of harm, serious functional impairment, or major co-occurring conditions. The administrative record showed, among other things, that M.M. participated in conversations and that the evidence did not establish a danger to himself or others requiring the highest level of residential care.

Daniels Academy Treatment

The court also found substantial evidence supporting the denial of coverage for Daniels Academy from May 26, 2019, through May 21, 2021. The treatment records described goals involving anxiety management, social skills, executive functioning, independent living, and schooling. Although some records mentioned passive suicidal thoughts, they did not show suicidal intent, a plan, or serious self-harm urges. M.M. also made trips home and took a two-week family trip to Hawaii, which the court viewed as evidence supporting the possibility of treatment at a lower level of care with family support.

Dr. Solomon calculated a CASII score of 12 for the Daniels Academy period and concluded that M.M.’s conditions did not require 24-hour supervision. Another independent review found no acute psychiatric symptoms requiring residential care and characterized Daniels Academy as a structured teaching environment rather than a setting requiring 24-hour psychiatric monitoring. The court rejected the plaintiffs’ arguments that M.M.’s suicidal thoughts, prior school difficulties, ADHD, autism, and obsessive-compulsive disorder required a CASII Level Five residential placement.

The court therefore held that it was not arbitrary and capricious for the defendants to conclude that the uncovered treatment at Elevations and Daniels Academy did not satisfy the plan’s medical-necessity requirement. The defendants’ motion for summary judgment on the ERISA claim was granted, and the plaintiffs’ motion on that claim was denied as moot.

Mental Health Parity Claim

The plaintiffs also alleged that the defendants violated the Mental Health Parity and Addiction Equity Act of 2008 by using internal guidelines for mental-health treatment that were more restrictive than the guidelines used for comparable medical or surgical care. The challenged guidelines were the Optum Guidelines used in earlier, first-level appeal decisions.

The court did not decide whether the Optum Guidelines violated the Parity Act. Instead, it held that the plaintiffs lacked constitutional standing, meaning they had not shown a personal injury caused by the challenged conduct that a court decision could remedy. The Optum Guidelines were not used in the final appeals on remand; the defendants used CASII instead. Because the final denial was based on CASII, a ruling about the Optum Guidelines would not redress the plaintiffs’ alleged injury. The court also stated that the claim was deemed conceded because the plaintiffs did not respond to the defendants’ standing argument. The Parity Act claim was dismissed for lack of standing.

Disposition

Judge Lorna G. Schofield granted the defendants’ motion for summary judgment. The plaintiffs’ motion for summary judgment and request for oral argument were denied as moot. The Parity Act claim was dismissed for lack of standing, and the court directed the clerk to close the motions and the case.