- Filing. Published in U.S. District Court for the District of Utah on May 26, 2020 (Case no. 2:19-cv-00231-JNO-DAO).
- Backgroun Plaintiff’s minor child suffers from depression, eating disorder, chronic suicidal ideations, addiction issues among other MH issues. Anthem approved 21 days of treatment at a residential treatment facility and then denied care thereafter. Among other aspects of the review, Anthem did not afford the attending provider to have a peer-to-peer consult and changed the reason for the denial. At first the denial was based on the “progress toward treatment goals isn’t occurring and your treatment plan hasn’t been changed so that progress will be likely. For this reason, the request for you to remain in residential treatment is denied as not medically necessary.”
The denial was upheld on appeal for another reason, however: “After the treatment you had, you were no longer at risk of serious harm that needed 24-hour care. You could have been treated with outpatient services.”
The external review organization upheld the denial without clarifying which reason applied. Plaintiffs asserted both an ERISA breach of fiduciary claim and a Parity Act violation claim.
- Holding. Judge Jill N. Parrish denied the Defendant’s motion to dismiss.
- Analysis. Judge Parrish walked through the framework of a Parity Act violation claim. For example, she notes that Plaintiffs identified a MH coverage limitation when the Plan noted “that residential treatment was not medically necessary because the minor was not progressing in her treatment plan after only 21 days of treatment.” She observed that a medical/surgical analogue was identified in this case such as care being rendered in “skilled nursing facilities, in patient hospice care, and rehabilitation facilities.” The Plaintiffs also asserted an “as-applied disparity” noting that Anthem does not apply a 21-day time limit for medical/surgical care.
Defendants argue in part that Plaintiffs do not allege sufficient facts to support their conclusion that Anthem applies its medical necessity criteria more stringently to MH residential treatment to similar medical/surgical treatment. In response Judge Parrish writes “But the court recognizes that the Parity Act ‘counsels against a rigid pleading standard’ because of the disparity of information between plaintiffs and defendants regarding the treatment limitations claims administrators apply to the analogous medical care that a plaintiff did not seek.”