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Dailey v. Blue Cross

United States District Court, W.D. Missouri, Western Division

February 11, 2019





         Pending 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.[1] 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 denied.


         A. R.H.'s Medical History and Treatment

         R.H. 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.

         On 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.

         One day 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.

         B. R.H.'s Coverage Under the Plans

         R.H. is 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 provider;
d. Consistent with the attainment of reasonably achievable outcomes; and
e. Reasonably calculated to result in the improvement of the Covered Person's physiological and psychological functioning.

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).

         New 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 ...

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