1. Case Name: Ariana M. v. Humana Health Plan of Texas, Inc.
2. Type of Treatment Services Denied: Partial Hospitalization for Eating Disorder Treatment
- Plaintiff: Hames C. Plummer and Amar Bharat Raval, Berg Plummer Johnson & Raval, LLP; Lisa Kantor and Elizabeth Green, Kantor & Kantor, LLP
- Defendant: Carlos Ramon Soltero, Cleveland Terrazas, PLLC
4. Format: Memorandum and Opinion
- ERISA Claim? Yes
- Class Action/or Individual Action: Individual
- Defendant: Insurer and Plan
- Type of Insurance Plan: Employee Welfare Benefits Plans under ERISA
- Type of Coverage Denial: Medical Necessity
6. Legal Pointer: The Fifth Circuit acknowledged that its standard of review for ERISA cases was at odds with that of most circuits and changed the law, holding that district courts were to review de novo a plan administrator’s decision to deny coverage under an ERISA plan.
7. Legal Issues and Causes of Action: Ariana M. sued Humana Health Plan of Texas, Inc. alleging that Humana had wrongfully denied benefits for 106 days of partial hospitalization to treat an eating disorder. Humana had paid for 49 days of partial hospitalization before determining that Ariana M. did not meet the criteria for continued coverage at that level. Instead, she was covered for the next level of care – intensive outpatient. The U.S. District Court for the Southern District of Texas granted summary judgment for Humana, holding that it did not abuse its discretion in denying the benefits. Ariana M. appealed. On appeal, the Fifth Circuit acknowledged that its standard of review for ERISA cases was at odds with that of most circuits and changed the law. The Fifth Circuit held that district courts are to review de novo a plan administrator’s decision to deny coverage under an ERISA plan. The Fifth Circuit vacated the order granting summary judgment and remanded for the District Court to apply the de novo
- Ruling: Humana’s Motion for Summary Judgment and Motion to Strike were granted and Ariana M.’s Cross-Motion for Summary Judgment and Motion for Attorneys’ Fees were denied.
8. Narrative Case Description: On remand, Ariana M. moved for summary judgment arguing that her partial hospitalization remained medically necessary after June 4, 2013, citing Dr. Rosko’s opinion that she was “at high risk of relapse and self-harm” if she left partial hospitalization. Ariana M. further argued that the Mihalik criteria were inadequate and that Humana failed to provide them to her during the administrative process. In the alternative, Ariana M. argued that she met the Mihalik criteria between June 4 and September 18. Humana argued that Ariana M.’s claim for continued partial hospitalization received full and fair review and that the Mihalik criteria incorporated national standards of medical practice, as required under the plan. Humana further argued that Ariana M. was not a danger to herself or others, was medically stable, was on stable medication, was maintaining a healthy body weight, was confronting her problems and was not cutting herself or engaged in eating disorder behaviors that changed her weight. As such, Humana concluded that Ariana M. could be treated in intensive outpatient care near her home.
The Court reviewed the administrative record de novo to determine whether Humana wrongfully denied Ariana M. benefits for her partial hospitalization starting from June 5 to September 18, after paying benefits from April 15 to June 4. In doing so, the Court first had to determine whether the Mihalik criteria were consistent with Ariana M.’s plan and reflected national standards of care for mental health treatment. If so, the Court then had to determine whether Ariana M.’s continued partial hospitalization was medically necessary under the national standards.
The Court opined that nothing in the Mihalik criteria’s definition of medical necessity was inconsistent with the Plan’s terms and that Ariana M. had not identified evidence showing that the Mihalik criteria fall below, fail to reflect, or conflict with national standards of care. As such, Humana did not err in using the Mihalik criteria to assess medical necessity.
The Court further opined that a de novo review of the administrative record revealed that Humana made no error in denying benefits for Ariana M.’s partial hospitalization after June 4 as she had to meet eight (8) “General Criteria” throughout “the episode of care” and failed to satisfy two (2) of them: “The services must be individualized, specific, and consistent with the individual’s signs, symptoms, history, and diagnosis” and “The individual complied with the essential elements of treatment.” More specifically, after 49 days in partial hospitalization, Ariana M. had stabilized and improved enough to transition to a lower level of care, thus partial hospitalization was no longer required by the plan terms given her symptoms, history and diagnosis. Additionally, because Ariana M. did not cooperate with her treatment, she failed the compliance criterion.
Ariana M. also had to meet six (6) “Treatment Criteria” for “each day that services were provided” and failed to meet at least one (1) of them: “The individual does not have adequate internal resources or an adequate external support system to maintain functioning without the support of an intensive multi-modal, multi-disciplinary treatment program that includes medical and/or nursing care.” In particular, the administrative record showed that Ariana M. had demonstrated the internal resources necessary to largely control her behaviors, with none of the more self-destructive acts, and to resist those urges over the 49 days in treatment. Thus, this criterion was not met as of June 4.
The Court further found Ariana M. also failed to satisfy the “Treatment Initiation Criteria” as she did not pose a clear and present danger to herself and others, was physically healthy, did not attempt to harm herself, and did not have suicidal, homicidal or psychotic thoughts. Ariana M.’s health and improvement supported to the reviewers’ finding that she did not require the higher level of care of partial hospitalization and could move to intensive outpatient care.
Lastly, Ariana M. had to satisfy six (6) “Treatment Continuation” during “the episode of care” and she failed to meet at least one (1) of them: “The treatment goals, interventions, time frames, anticipated outcomes, discharge plan, and criteria for discharge are clinically efficient, reasonable, and achievable in the length of stay typically associated with treatment at this level.” The record did not contain a structured plan to transition Ariana M. out of partial hospitalization and therefore this criterion was not met.
As such, based on the pleadings, the parties’ arguments and submissions, the administrative record, and the applicable law, the District Court granted Humana’s Motion to Strike and Motion for Summary Judgment and denied Ariana M.’s Cross-Motion for Summary Judgment. The Court held that the de novo review of the administrative record revealed that Ariana M.’s continued partial hospitalization was not medically necessary after June 4, 2013, after she had been covered for 49 days.
9. Additional Comments: Humana additionally moved to strike the attachments to Ariana M.’s Motion for Summary Judgment which included medical records and reports from April to September, the deposition from Dr. Hartman, an independent reviewer, unrelated to litigation, and her father’s notes from a conversation he had with the Mihalik Group, stating that the evidence was outside the administrative record. Ariana M. asserted that the Court could admit the additional documents because at least some of them contained information available to Humana when it denied her claim, but Ariana M. failed to explain which documents were available, or how she submitted the documents to the plan administrator during the administrative process. Ariana M. also contended that the documents could help the Court understand the record; however, the Court opined that Ariana M. used the documents to argue that Humana’s review process was inadequate and that her partial hospitalization was medically necessary, which question the merits of the case, and did not illustrate how Humana had interpreted the plans terms in the past. As such, the Court granted Humana’s Motion to Strike. Ariana M.’s Motion for Attorneys’ Fees was also denied.
10. Website: Fifth Circuit Opinion: https://law.justia.com/cases/federal/appellate-courts/ca5/16-20174/16-20174-2018-03-01.html
11. Practical Implications and Lessons Learned: Sitting en banc, the Fifth Circuit overturned the panel decision and changed the standard of review of a plan administrator’s factual determinations from abuse of discretion to de novo.
12. All Legal Theories Presented in Case: Violation of ERISA
13. Successful Legal Theories in Case: None.