By Jessica Grillo, J.D., Legal Advisor for The Kennedy Forum
Todd and Suzanne struggled for years to help their daughter, Lillian, cope with mental health disorders. Dr. Ghosh, a psychiatrist who treated Lillian, ultimately recommended inpatient residential care. Mr. Summer, a licensed clinical social worker who also worked with Lillian, agreed that nothing else could be done for Lillian on an out-patient basis and recommended that her parents place her in residential treatment.
On January 1, 2014, Lillian’s parents admitted her Elevations Residential Treatment Center. Dr. Brockbank, an examining psychologist, conducted a comprehensive psychological evaluation of her and strongly recommended that Lillian complete the program at Elevations. Dr. Brockbank concluded that unless some change could occur on the family-system level, it was unlikely that Lillian would be successful at home. Lillian was treated at Elevations until June 21, 2015.
Lillian’s parents sought reimbursement from Premera for the residential treatment that Lillian received at Elevations; however, Premera denied the claim as not medically necessary. Lillian’s parents appealed Premera’s denial though an internal appeal process (Level I Appeal). As a part of the Level I Appeal, Premera asked an Independent Physician Reviewer to review its decision to deny coverage. Dr. Holmes reviewed the Level I Appeal submission and concluded that the service provided was not medically necessary. Lillian’s parents then requested a Level II Appeal. To review the Level II Appeal, Premera assigned a panel consisting of (1) a physician who was a medical director and board certified in internal medicine, (2) a Member Contracts Operations Manager, and (3) a New Group and Product Implementation Manager. The Level II Appeal panel upheld Premera’s Level I Appeal determination denying coverage. Lillian’s parents requested an independent review of Premera’s decision. MCMC conducted the independent review and Premera’s denial of coverage was upheld.
A lawsuit was filed wherein Lillian’s parents argued that the sixth risk listed in Premera’s Medical Policy provided that “residential care was appropriate for an adolescent where the patient was stabilized during an inpatient treatment stay for severe symptoms or behavior and required a structured setting with continued around-the-clock behavioral care.” Premera responded in two ways. First, Premera stated that Lillian’s care did not qualify within the sixth risk listed in Premera’s Medical Policy and therefore was not medically necessary. Second, Premera argued that the sixth risk listed in the Medical Policy did not even apply because it required the adolescent patient to have stabilized during an inpatient treatment stay for severe symptoms and Lilian’s residential treatment stay at Elevations did not qualify as an inpatient treatment stay. Premera argued that the term “inpatient” referred solely to inpatient hospital stays and not to residential treatment center stays, and thus, the sixth risk did not apply because Lillian was never in inpatient hospitalization.
The Court evaluated these two arguments separately.
Plan Language and Medical Policy’ Sixth Risk
The Court concluded that the term “inpatient,” as it was used in the sixth risk listed in Premera’s Medical Policy was not limited solely to hospital admissions but applied to admissions at other healthcare facilities, including residential treatment centers such as Elevations. Despite Premera’s argument that its Medical Policy limits the term “inpatient” to circumstances involving a hospital admission, the Court found no such limitation in the language of the Medical Policy. More specifically, the admission guidelines for adolescents to residential care contained in Premera’s Medical Policy did not (1) specifically define the term “inpatient” as that term was used in the sixth risk, or (2) expressly limit the term “inpatient” to mean only hospital admissions. Further, the terms “inpatient” and “residential care” were used interchangeably throughout the medical records and Premera repeatedly described Lillian’s residential care at Elevations as “inpatient” throughout its own briefing. Thus, the Court concluded that the language of the Plan itself supported the conclusion that the term “inpatient” referred to a broader category of overnight stays than just hospitalizations. As such, Lillian’s treatment at Elevations fell within the Plan’s definition of “inpatient” as someone who was admitted to a healthcare facility for an overnight stay.
The Court also held that Lillian’s initial admission to Elevations was for severe symptoms as was required under the sixth provision of Premera’s Medical Policy. During the months immediately preceding Lillian’s admission to Elevations, she ran away from home twice, became assaultive with her mother and began self-injurious behaviors. Thus, the Court rejected Premera’s position that the sixth risk contained in its Medical Policy was inapplicable.
Evidence of Medical Necessity
The Court concluded that Premera’s decision that the treatment at Elevations did not fall within the sixth risk delineated in Premera’s Medical Policy and therefore was not medically necessary, was improper. The Court opined that Premera failed to adequately consider and/or evaluate certain portions of the medical record and records submitted, including Dr. Brockbank’s evaluation and recommendation and clinical notes showing that Lillian continued to experience suicidal and self-harm ideation and urges while at Elevations. As such, the Court held that Lillian’s parents met their burden of proving that Lillian’s treatment at Elevations was medically necessary.
The Court concluded that Premera improperly denied Lillian’s claim and ordered additional briefing by the parties to determine the amount of damages for which Premera was liable.
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Key Takeaway
The Court gave more weight to Lillian’s treating providers’ reports and opinions over the conclusions of Premera’s internal reviewer, review panel, and external reviewer. Therefore, it is important for plan beneficiaries to file appeals and exhaust their insurer’s appeal process when they believe their mental health and/or substance use benefits have been wrongfully denied.
Parity Resources from The Kennedy Forum
The Kennedy Forum’s “Don’t Deny Me” campaign empowers patients and their loved ones to report illegal insurance denials of mental health and addiction treatment, and fight for their parity rights. The campaign is sparking a consumer-driven movement that pressures elected officials, insurance commissioners, and attorneys general to enforce The Federal Parity Law. This law requires most insurers to cover illnesses of the brain, such as depression or addiction, no more restrictively than illnesses of the body, such as diabetes or cancer. Learn more at www.DontDenyMe.org and join the conversation using#DontDenyMe.
Parity Track is a website where policymakers, journalists, consumers, and others can track legislative, regulatory, and legal parity activities in all 50 states and at the federal level to monitor implementation and best practices.
