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Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 

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United States Court of Appeals

FOR THE EIGHTH CIRCUIT

___________

No. 04-1383

___________

Jo Ortlieb, *

*

Appellant, *

* Appeal from the United States

vs. * District Court for the

* District of Nebraska.

United HealthCare Choice Plans, *

c/o United HealthCare of the *

Midlands, Inc.; United HealthCare *

of the Midlands, Inc., as Administrator *

Fiduciary of the Plan; United *

HealthCare Insurance Company, *

*

 Appellees. *

___________

Submitted: August 26, 2004

Filed: October 28, 2004

___________

Before BYE, LAY, and RILEY, Circuit Judges. 

___________

RILEY, Circuit Judge.

Jo Ortlieb (Ortlieb) was insured under a United HealthCare Choice Plus Plan

(Plan) when she became seriously ill. Her treating physician prescribed Total

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Total Parenteral Nutrition describes the delivery of nutrients for assimilation

and utilization of nutrients via solutions administered to patients intravenously,

subcutaneously, or by some other non-alimentary route. Protein hydrolysates or free

amino acid mixtures, monosaccharides, and electrolytes are the basic components of

TPN solutions, which are selected for their ability to reverse catabolism, promote

anabolism, and build structural proteins. See http://www.online-medicaldictionary.org. 

2

The Honorable Thomas M. Shanahan, United States District Judge for the

District of Nebraska.

2

Parenteral Nutrition (TPN).1

 Ortlieb requested coverage for TPN, but the defendants

(collectively United HealthCare) denied coverage. After exhausting her

administrative remedies, Ortlieb filed an action under the Employees Retirement

Income Securities Act of 1974 (ERISA) to recover unpaid health care benefits. The

district court2

 granted summary judgment in favor of United HealthCare. Ortlieb

appeals. We affirm.

I. BACKGROUND

While working for her husband’s business, Ortlieb enrolled for healthcare

benefits under the group Plan issued by United HealthCare. The Plan provided that

United HealthCare “has sole and exclusive discretion in interpreting the benefits

Covered under the Policy and the other terms, conditions, limitations and exclusions

set out in the Policy and in making factual determinations related to the Policy and

its benefits.” The Plan excluded certain healthcare services, including experimental,

investigational, or unproven services. However, the Plan contained an express lifethreatening condition exception to the experimental, investigational, or unproven

service exclusion. The exception provided:

The PLAN, in its judgment, may deem an Experimental,

Investigational or Unproven Service a Covered Health Service for

treating a life threatening Sickness or condition if it is determined by the

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PLAN that the Experimental, Investigational or Unproven Service at the

time of the determination:

A. Is safe with promising efficacy; and

B. Is provided in a clinically controlled research setting; and

C. Uses a specific research protocol that meets standards equivalent

 to those defined by the National Institutes of Health. 

When Ortlieb became seriously ill, she initially received medical treatment in

Lincoln, Nebraska, and later at the Mayo Clinic in Rochester, Minnesota. As her

health continued to fail, she sought treatment at the Environmental Health Center

(EHC) in Dallas, Texas, under the medical supervision of Dr. William J. Rea (Dr.

Rea). Dr. Rea diagnosed Ortlieb with a myriad of illnesses, including toxic

encephalopathy, malnutrition, malabsorption, irritable bowel syndrome, allergic food

gastroenteritis, toxic effect petrochemicals and solvents, and fatigue. Dr. Rea

prescribed Ortlieb various treatments, including TPN therapy, which she began in late

October 1999. 

The pharmacy supplying Ortlieb’s TPN services submitted a coverage request

to United HealthCare for TPN and TPN-related services. Based on an internal

medical review conducted by Dr. Debra Esser (Dr. Esser), United HealthCare denied

the coverage request finding that TPN, as it related to malnutrition, fell within the

Plan’s experimental, investigational, or unproven service exclusion. In December

1999, United HealthCare notified Ortlieb of its decision to deny coverage.

In February 2000, the pharmacy sought reconsideration of the coverage denial,

and attached to its request a letter written by Dr. Rea describing Ortlieb’s medical

condition and Dr. Rea’s course of treatment. Later, in March 2000, Ortlieb appealed

the initial denial of coverage. United HealthCare hired Dr. Robert A. Beer (Dr. Beer),

an outside consulting physician, to review Ortlieb’s medical records and to

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recommend a benefit determination under the Plan. Dr. Beer recommended United

HealthCare deny coverage, which it did. 

Ortlieb appealed the second coverage denial. Her intermediate appeal was

reviewed by United HealthCare’s Consumer Affairs Committee (CAC), which

included an internal physician member, Dr. Tim Mergens (Dr. Mergens). The CAC

upheld the denial of coverage for TPN and related services. Ortlieb made a final

appeal to the National Appeals Service Center (NASC). NASC is administered by

Edina, an external review company. Edina, in turn, hired Dr. Arnold Flick (Dr.

Flick), an independent, board-certified gastroenterologist to review Ortlieb’s medical

records. Dr. Flick concluded insufficient medical literature existed to support TPN

treatment for any of Ortlieb’s proven medical conditions. 

Thereafter, Ortlieb contested the denial of coverage by filing her case in the

district court. The district court reviewed the benefit determination using an arbitrary

and capricious standard of review. In opposing United HealthCare’s motion for

summary judgment, Ortlieb submitted four technical documents discussing TPN,

none of which were included in the administrative record. The district court declined

to consider the new evidence. Based on the administrative record, the district court

determined United HealthCare reasonably relied on the assessments of multiple

doctors that TPN was an unproven therapy for Ortlieb’s medical conditions. The

district court rejected Ortlieb’s argument that United HealthCare had failed to

consider the “life-threatening condition” exception to the unproven service exclusion.

The court granted summary judgment in favor of United HealthCare. Ortlieb now

appeals.

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II. DISCUSSION

A. Standards of Review

We review de novo a district court’s grant of summary judgment, viewing the

record in the light most favorable to the nonmoving party. Butts v. Cont’l Cas. Co.,

357 F.3d 835, 837 (8th Cir. 2004) (citing Woo v. Deluxe Corp., 144 F.3d 1157, 1160

(8th Cir. 1998)). We also review de novo a district court’s determination of the

standard of review of an ERISA benefit plan determination. See Ferrari v. Teachers

Ins. and Annuity Ass’n, 278 F.3d 801, 806 (8th Cir. 2002).

The Supreme Court has declared a de novo standard of review applies to a

challenge to the denial of benefits, unless the benefit plan grants the plan

administrator discretionary authority to determine eligibility for benefits or to

construe the terms of the plan. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101,

115 (1989). When a plan gives discretion to the plan administrator, then a plan

administrator’s decision is reviewed judicially for an abuse of discretion. Id. Under

an abuse of discretion standard of review, a plan administrator’s decision will stand

if reasonable; “i.e., supported by substantial evidence.” Fletcher-Merrit v. Noram

Energy Corp., 250 F.3d 1174, 1179 (8th Cir. 2001) (quoting Donaho v. FMC Corp.,

74 F.3d 894, 899 (8th Cir. 1996)). “Substantial evidence . . . means such relevant

evidence as a reasonable mind might accept as adequate to support a conclusion.” Id.

(quoting Consol. Edison Co. of New York v. NLRB, 305 U.S. 197, 229 (1938)). 

 

In order for a plan beneficiary to obtain a less deferential standard of review,

she “must present material, probative evidence demonstrating that (1) a palpable

conflict of interest or a serious procedural irregularity existed, which (2) caused a

serious breach of the plan administrator’s fiduciary duty to her.” Woo, 144 F.3d at

1160. To establish the second requirement, a plan beneficiary “must only show that

the conflict or procedural irregularity has ‘some connection to the substantive

decision reached.’” Id. at 1161 (quoting Buttram v. Central States, S.E. & S.W. Areas

Health & Welfare Fund, 76 F.3d 896, 901 (8th Cir. 1996)). 

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 In this case, the Plan granted United HealthCare, as plan administrator, “sole

and exclusive discretion in interpreting the benefits Covered under the Policy.” We

agree with the district court that the Plan’s “express discretion-granting language” is

sufficient to confer discretionary authority upon United HealthCare. Therefore, the

district court properly reviewed the benefit decision for an abuse of discretion. We

also agree with the district court that Ortlieb failed to present material, probative

evidence demonstrating either a “palpable conflict of interest” or “a serious

procedural irregularity,” which would warrant applying a less deferential standard of

review. 

B. Reasonableness of Benefit Decision

Our record review convinces us that United HealthCare’s decision to deny

coverage is supported by substantial evidence and is, therefore, reasonable. The

record indicates that, at the direction of Dr. Rea, Ortlieb commenced TPN treatment

in late October 1999 and then sought coverage from United HealthCare. Upon

receiving a request for TPN coverage, United HealthCare requested additional

medical records, which were received in mid-November 1999. Dr. Esser initially

reviewed Ortlieb’s medical records and consulted with Ortlieb’s primary care

physician and gastroenterologist. Based on her record review and consultations, Dr.

Esser determined TPN services were investigational and were not supported by peer

literature. On December 7, 1999, Dr. Esser wrote Ortlieb explaining United

HealthCare was denying coverage based on the Plan’s exclusion for experimental,

investigational, and unproven services.

Within weeks of denying coverage, United HealthCare received a request for

reconsideration accompanied by a detailed letter from Dr. Rea. Although Dr. Rea’s

letter declared Ortlieb’s receipt of TPN services was “a medical necessity” and also

stated TPN therapy had been used at the EHC clinic “for over twenty-five years with

more than five thousand patients and . . . no significant long-term effects have been

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noted,” Dr. Rea’s letter cited no peer-reviewed medical literature indicating TPN

services are a safe and effective treatment for Ortlieb’s medical conditions. 

Because the reconsideration request included a first-time coverage request for

intravenous mineral and antibiotic therapy, United HealthCare requested additional

medical records. In March 2000, Ortlieb formally appealed the initial denial of

coverage, and in April 2000, United HealthCare hired Dr. Beer, an outside physician

consultant, to review Ortlieb’s medical records and to make an independent benefit

determination. Dr. Beer determined (1) the records reflected “insufficient objective

data for cause of malnutrition”; and (2) the requested TPN services were

“investigational” and unsupported by sufficient medical evidence in Ortlieb’s case or

in the literature indicating any clinical improvement. Based on these findings, Dr.

Beer recommended denial of coverage. 

Near the same time, Dr. Esser reviewed the coverage request for Ortlieb’s

supplemental intravenous mineral and antibiotic therapy services. Relying on the

documentation provided, Dr. Esser determined the requested TPN therapy services

were investigational and not a covered benefit. On May 23, 2000, Dr. Esser wrote

two denial-of-coverage letters. One letter notified Ortlieb that United HealthCare was

denying the coverage request for supplemental, intravenous mineral and antibiotic

therapy services. Dr. Esser’s letter explained:

There is no documentation of positive cultures of an infection that

would require intravenous antibiotics. It is also documented in your

records that you are “allergic to all antibiotics,” yet intravenous

antibiotics were given. Without supporting documentation of an

infection, use of antibiotics is considered investigational and not a

covered benefit. 

Dr. Esser’s second letter denied Ortlieb’s request to reconsider the initial denial

of coverage for TPN services. Although the letter did not refer to Dr. Beer by name,

Dr. Esser informed Ortlieb her file “has been carefully reviewed by a physician

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consultant who was not involved in the initial decision,” which had resulted in an

independent determination that the previous decision should be upheld. Dr. Esser

explained:

There is also insufficient evidence in your medical records and peerreviewed medical literature that TPN (and especially

vitamin/mineral/anti-oxidant supplementation) results in clinical

improvement. Therefore, the use of TPN is considered investigational

and the TPN, supplies, and skilled nursing visits are not covered under

your benefit plan.

Ortlieb then pursued an intermediate appeal to the CAC. United HealthCare

representatives, including physician member Dr. Mergens, reviewed Ortlieb’s file and

upheld the decision to deny coverage. United HealthCare notified Ortlieb of the

CAC’s decision in January 2001, citing, as the basis for denial, the experimental,

investigational, or unproven service exclusion. 

Ortlieb filed her final administrative appeal with the NASC, which was

independently processed by Edina, an external review company. Edina retained Dr.

Flick, an independent, board certified, gastroenterology consultant. In August 2002,

Dr. Flick reviewed Ortlieb’s medical records and found no peer-reviewed literature

supporting TPN therapy treatment for any of Ortlieb’s proven diagnoses. Dr. Flick

concluded TPN treatment to be “unproven for [Ortlieb’s] clinical condition(s).”

Edina notified Ortlieb that, based upon an independent external review, TPN was not

a covered service because “TPN treatment is unproven for Ms. Ortlieb’s clinical

condition,” and unproven services are excluded under the Plan. 

This recitation of the record illustrates that Ortlieb’s coverage request for TPN

therapy was reviewed at least four times by four physicians, two of whom were

external, independent physician consultants. Each of the physicians reviewing

Ortlieb’s medical file consistently determined TPN therapy was an unproven therapy

for Ortlieb’s medical conditions. At least three of the four reviewing physicians

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Ortlieb also argues United HealthCare should be strictly bound to the grounds

for its original denial. After initially denying coverage for TPN therapy, United

HealthCare continued to assess and investigate Ortlieb’s claim, at Ortlieb’s request.

As the administrative process evolved, United HealthCare learned more about

Ortlieb’s claim and the medical field’s recognition of her conditions and TPN

therapy. United HealthCare’s further investigation is commendable and should be

encouraged, not discouraged. On this record, to the extent United HealthCare’s

grounds for denial changed, we see no justification for limiting United HealthCare’s

reasons for denial.

9

concluded there was insufficient peer-reviewed literature supporting TPN therapy for

Ortlieb’s medical conditions. All five denial-of-coverage notices explained Ortlieb’s

coverage request for TPN therapy and related services was being denied based on the

Plan’s exclusion for experimental, investigational, or unproven services. All but the

final denial notice, which was issued by Edina, specifically cited to and quoted the

Plan’s exclusion provision. Moreover, Dr. Esser’s May 2000 letter informed Ortlieb

there was “insufficient . . . peer-reviewed medical literature that TPN . . . results in

clinical improvement.” Despite receiving these notices that clearly and consistently

identified the bases for coverage denial–unproven service and insufficient peerreviewed medical literature–neither Ortlieb nor her treating physician provided

United HealthCare with clinical evidence or peer-reviewed literature establishing

TPN therapy was a proven therapy for Ortlieb’s medical conditions. For these

reasons, we conclude Ortlieb’s arguments are without merit, and United HealthCare’s

denial of coverage is reasonable.3

 

C. Life-Threatening Condition Exception

Ortlieb also argues United HealthCare was not entitled to summary judgment,

because a genuine issue of material fact exists as to whether United HealthCare

considered Ortlieb’s medical condition as life threatening, an express exception to the

Plan’s experimental, investigational, or unproven service exclusion. United

HealthCare contends the life-threatening exception does not apply for two reasons:

(1) Ortlieb’s medical records do not establish her medical condition was life

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threatening, and (2) TPN therapy, as utilized in this case, was not a treatment “safe

with promising efficacy,” part of a clinical study, or performed according to specific

research protocol.

 The district court concluded that, although United HealthCare never expressly

stated it considered and rejected the Plan’s life-threatening condition exception, Dr.

Flick addressed the first required element of the exception by questioning the efficacy

of TPN treatment for Ortlieb’s medical conditions and by identifying several adverse

side effects related to TPN therapy. Moreover, the district court determined the

record contained no evidence that Ortlieb’s TPN therapy at EHC was “provided in a

clinically controlled research setting” and “[used] specific research protocol that

meets standard[s] equivalent to those defined by the National Institutes of Health.”

We agree with the district court’s conclusion that United HealthCare’s independent

medical expert, Dr. Flick, at least implicitly considered and rejected the lifethreatening condition exception, and his decision in doing so was reasonable. If

Ortlieb’s medical condition were life-threatening, which is dubious based on this

record, United HealthCare’s reliance on Dr. Flick’s opinions and on the

administrative record is reasonable, and its decision to deny benefits is supported by

substantial evidence. 

III. CONCLUSION

For the foregoing reasons, we affirm the well-reasoned judgment of the district

court. 

______________________________

 

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