about the confinement of a child at a residential treatment center a significant and serious action in the life of a child this particular child was confined for eighteen months at this residential treatment center it is also a case about an example of the robust rubio that arista claim members receive when seeking benefits under their arista plan this particular claim received an ample due process and multiple review this claim received four levels of administrative review every single one of those ruby is concluded that lilian's confinement at the relevance of treatment center was not medically necessary at every level of rosy view the members were invited to submit whatever information and that evidence they wish to submit to armies appeals were done by independent child psychologists with no affiliation with primera at all the last one of these reviews was a mandated by the affordable care act and done by an independent review organization which again find it to a completely independent terms of the contract and find covered under the contract language the district court relied on the six prong in the medical policy at issue which also the patient has currently stabilized from another of residential care there is no evidence that lillian ever came from a hospital or in patient treatment and so this problem just simply doesn't apply and it may ensure point your honor about the evidence actually when you look at the record of what the evidence is here is ringback there is not evidence of self harm contemporaneous with the confinement it is not it is not the insurance company's that ish and that really and doesn't merit care for her significant mental health issues she does this is actually the about issue receiving the right type of care at the right level and the position here of every reviewer who looked at it is she what we're doing isn't working residential treatment is call for the professional to created her prior did not see her at the time of her confinement and indeed the one that they rely in most had not is the level of intensity of services that this child is receiving she cannot leave she is monitored twenty four so that she is in a very confined situation so let's talk about what dr grokking six before the actual admission to residential care but he said in my opinion and patient residents were here was the only option and goes on to refer specifically to the placement i would view productive or more compelling than other evidence is there any evidence is there any finding of the criteria in the medical policy and you make that you have to have evidence somewhere in the record different question that providers you know what i think she would benefit from being here she may benefit from being here but the question that you are answering is a different one which is under the terms of the policy is the correct problem is that my parents do not believe i am a girl my parents believe that i am a boy and that is the problem i am not going to hurt myself and i do not need to be locked up here and that is important because you your will we are going to do an intake assessment by the way it was not done by the doctor it was done by a social worker the social worker from a checklist say this child is not a threat to herself or others the child is here because the family state that she no longer wants to be a part of our family the child states the problem is my parents believe i am a girl and they want me here because the issue that is not are we can concede that however they are not covered under her insurance which covers intervention if she does not need the level of medical intervention it will not be covered review specialists say this particular treatment is not medically necessary for this person and again they're not saying it may not benefit her or she may not get something out of a therapeutic boarding school setting she may is in place to do is to relieve the burden in this case upon the court of appeals and and true indicate that there needs to be a time that comes and goes for parties to present their arguments and present the facts and for a finding to be entered by either the district court or it mystery's the border bills to do that i suppose but i think that in order to give rule fifty two meaning it would be appropriate to bit of evidence this is medically necessary but if a car really does a look at it after that point where there are improvements and so on is this the kind of situation where we should spend at least that portion of the case back to the district judge to have inpatient treatments they were severe symptoms or behavior and require structured setting with insinuate around the behavioral error that would suggest to us that and i think it's just this report what you were looking at was an individual who was people in other words not acutely ill not at imminent threat of harm to stop or others but was in need of long term treatment to ensure that satisfied i'm fine with that result obviously fight with the result but but as somebody who's probably in the strip or both of you you're more versed in this field of law then your average distr know the district judge here i don't know what is based on his but i suspect this is routinely the case you're certainly more versed in this field than any of the three of us are and my colleagues quite well so i'm going to argue to a different ur own direction with it not to say that there's not a good argument you may need many well of made it but that's not what the district court so i will confess some concern about proceeding down the path the district court  satisfied but you know again i think that the dealer is additional evidence to speak to that subject i guess it came up in the form of the motion for the time of the motion for reconsideration is recorded so not too late for any of this so it is not like the court was really open for business today to this is this issue here is oral argument he did properly give notice to the parties review in the way that the district or barely reflected x in the medical records so i think that when you look at the language of the criterion so when you look at the arguments that america has basically saying that the treatment was not medically necessary in a period of time the time where you are beginning your claim in may two thousand and four day they object to the continued placement of the chip out of that facility at that time well they didn't object in the sense that they left the parents to do whatever they wanted with the big we're never come along and say you know you can keep  response to your question judge fisher the parents didn't submit the claim until the fall so she had already been there for a significant amount of time before they even submitted that claim for pre authorization which is required and then you see there is a reason that congress has enacted the requirements of arista and put in all of these requirements and then on top of that we have this affordable care act independent review done by an independent child psychologist that by the way child and adolescent psychologist and we have multiple of them looking at these planes every single one of them concluding that the criteria for medical necessity is not met one of the things that was very troubling to the child psychologist