United States District Court, W.D. Missouri, Western Division
ORDER AND OPINION (1) GRANTING DEFENDANTS' MOTION
FOR SUMMARY JUDGMENT, AND (2) DENYING PLAINTIFF'S MOTION
FOR SUMMARY JUDGMENT
D. SMITH, SENIOR JUDGE
are the parties' cross motions for summary judgment.
Docs. #38, 40. This action challenges a denial of health
insurance benefits. Plaintiff is R.H.'s mother. Plaintiff
and R.H., as Plaintiff's beneficiary, were insured under
Blue KC's 2016 Health Benefits Certificate (2016
Certificate), and Blue KC's 2017 Health Benefits
Certificate (2017 Certificate), through Plaintiff's
employer. The Plans were administered by Defendant
Blue Cross and Blue Shield of Kansas City
(“BCBSKC”), and governed by the Employee
Retirement Income Security Act of 1974, as amended 29 U.S.C.
§ 1001, et. seq. (“ERISA”).
Plaintiff alleges that BCBSKC improperly denied reimbursement
for inpatient mental health treatment that R.H. received at
the Elements Wilderness Program (“Elements”) and
Boulder Creek Academy (“Boulder Creek”) from
January 20, 2016, to March 17, 2017. For the following
reasons, Defendants' motion for summary judgment is
granted, and Plaintiff's motion for summary judgment is
R.H.'s Medical History and Treatment
has a long history of mental health issues, including
Obsessive Compulsive Disorder and an eating disorder, and
behavioral problems, including anger outbursts and aggression
towards family members and property. Doc. #37, at 1229, 2663.
Before being insured by the Plans, R.H. had a history of
outpatient, intensive outpatient, partial hospitalization,
inpatient, and residential treatments. Id.
January 5, 2016, R.H. enrolled in a high school near St.
Louis, Missouri, but withdrew on January 14, 2016.
Id. On January 20, 2016, R.H. was admitted to
Elements, located in Utah. Id. at 1173. The level of
care at Elements is described as “intermediate outdoor
use mental health treatment services”. Id. at
1229. At Elements, R.H. received outdoor behavioral
healthcare designed to help him build skills related to
self-confidence, assertive communication, interpersonal
relationships, and coping skill management. Id. at
1220. The documentation from the facility notes R.H. was not
suicidal, homicidal, psychotic, or gravely disabled; he had a
history of superficial self-harm behaviors; and he was taking
his medications. Id. His eating disorder was
described as being in full remission. Id. R.H.'s
last day at Elements was March 17, 2016. Id. His
discharge diagnoses included Autism Spectrum Disorder, Major
Depressive Disorder, and Attention-deficit/hyperactivity
disorder (“ADHD”). Id.
later, R.H. was enrolled at Boulder Creek, located in Idaho.
Id. at 1453, 2394. At Boulder Creek, R.H. received
focused academic and therapeutic resources to help him gain
skills necessary to integrate back into his family and
society at large. Id. at 2159. After a year of
treatment, R.H. left Boulder Creek in March, 2017.
Id. at 2698.
R.H.'s Coverage Under the Plans
a participant in his mother's Plans, which BCBSKC funds
and administers. Under the proper circumstances, the Plans
provide coverage for medical and behavioral health services
including inpatient care, residential treatment, intensive
outpatient program, and routine outpatient treatment. The
Plans specify that such coverage will only be provided for
services that are “medically necessary.” Doc.
#37, at 36, 198. Under the Plans, “medically
necessary” means services and supplies which [BCBSKC],
utilizing additional authoritative sources of information and
expertise, determine are essential to the health of a covered
person and are:
a. Appropriate and necessary for the symptoms, diagnosis and
treatment of a medical or surgical condition;
b. In accordance with Our local medical policies, which are
consistent with acceptable medical practice according to the
national Blue Cross and Blue Shield Association's uniform
medical policy (as amended from time to time);
c. Not primarily for the convenience of the Covered Person,
nor the Covered Person's family, Physician or another
d. Consistent with the attainment of reasonably achievable
e. Reasonably calculated to result in the improvement of the
Covered Person's physiological and psychological
Doc. #37, at 22-23, 184-85. The Plans grant BCBSKC
“full discretion and authority to interpret and apply
the provisions” of the Plans. Id. at 107, 269.
Regarding mental health treatment and services, the Plans
state that services “for inpatient services are limited
to Hospital and Physician services when [the covered person
is] confined to any Hospital or other residential facility
licensed to provide such treatment. Inpatient
and Residential Mental Illness and Substance
Abuse Services must be Prior Authorized by
New Directions.” Id. at 51, 217
(emphasis in original).
Directions Behavioral Health, L.L.C., which is also named as
a defendant in this matter, provides managed behavioral
health care services for BCBSKC. Doc. #1, at 3. New
Directions utilizes Medical Necessity Criteria for
BCBSKC's health plans, which contain specific guidelines
about various levels of treatment and what constitutes the
medical need for specific levels of treatment. Doc. #37, at
320-86. The Plans allow a member to request a retrospective