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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF OHIO

WESTERN DIVISION

A.G., by and through her father, N.G.,

Plaintiff,

vs.

COMMUNITY INSURANCE 

COMPANY D/B/A/ ANTHEM BLUE 

CROSS AND BLUE SHIELD,

Defendant.

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Case No. 1:18-cv-300

Judge Timothy S. Black

ORDER RESOLVING CROSS-MOTIONS FOR

JUDGMENT ON THE ADMINISTRATIVE RECORD (Docs. 36, 38)

This civil action is before the Court upon Defendant Community Insurance 

Company d/b/a/ Anthem Blue Cross Blue Shield (“Anthem” or “Defendant”)’s motion 

for judgment on the administrative record (Doc. 36); Plaintiff’s motion for entry of 

judgment on the merits (Doc. 38)1

; and the parties’ responsive memoranda (Docs. 39, 

40). 

1 While Plaintiff’s motion is titled as one seeking “entry of judgment on the merits,” the motion is 

essentially one for judgment on the administrative record.

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I. PROCEDURAL HISTORY

On May 1, 2018, Plaintiff A.G., by and through her father, N.G.,2 filed this 

Employee Retirement Income and Security Act (“ERISA”) action arising from Anthem’s

decision to deny health plan benefits for allegedly medically necessary services. (Doc. 

1). Plaintiff’s four-count complaint challenged Anthem’s benefit determinations for her 

treatment at Blue Ridge Therapeutic Wilderness (“Blue Ridge”) and Sunrise Residential 

Treatment Center (“Sunrise”). On January 28, 2019, this Court granted Defendant’s 

partial motion to dismiss Counts 1–3,3 which pertained to Anthem’s benefit 

determination for A.G.’s treatment at Blue Ridge. (Doc. 28). The only remaining cause 

of action—Count 4—seeks benefits for A.G.’s treatment at Sunrise under 29 U.S.C. 

§ 1132(a)(1)(B). (Doc. 1 at ¶¶ 54–62). 

2 During the relevant time period, N.G. and A.G. was an insured by Anthem through N.G.’s employersponsored health insurance. (Id. at ¶ 7) A copy of the insurance plan issued to N.G. by Anthem is 

attached to the Complaint. (Doc. 1-2 (the “Plan”)).

3 Count 1 was brought on behalf of A.G. and a proposed class, and sought enforcement of the Plan 

because Plaintiff contended that the services received at Blue Ridge were not excluded under the Plan. 

Count 2 sought enforcement of the Plan for breach of the protections of the Mental Health Parity and 

Addiction Act (“Parity Act”), which mandates parity between the “treatment limitations” placed on 

mental health benefits and medical/surgical benefits. (Doc. 1 at ¶¶ 40–48; 29 U.S.C. § 1185a

(a)(3)(A)(ii)). Count 3 was for breach of fiduciary duty for violation of the Parity Act. (Doc. 1 at ¶¶ 49–

53). 

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II. BACKGROUND FACTS4

A. The Plan

The Plan’s Health Certificate of Coverage (the “Certificate”) governs whether 

benefits are covered by Anthem. (DPUF at ¶ 2). If a service is covered by the terms of 

the Certificate (a “Covered Service”), the Plan provides benefits for the service. (Id at 

¶¶ 2,3). Covered Services must be (1) “Medically Necessary,” (2) within the scope of the 

license of the “Provider” performing the service, (3) rendered while coverage is in effect,

(4) not “Experimental/Investigative: or otherwise excluded by the Plan, and (5) 

authorized in advance when Anthem requires this procedure. (AG_ANTHEM_000114).

“Medically Necessary” means (1) appropriate for and consistent with symptoms 

and proper diagnosis and treatment; (2) obtained from a Provider; (3) provided in 

accordance with applicable medical and/or professional standards; (4) known to be 

effective in materially improving health outcomes; (5) the “most appropriate supply, 

setting or level of service that can be safely provided to the Member and which cannot be 

omitted consistent with recognized professional standards of care (which, in the case of 

4 To supplement its motion for judgment on the administrative record, Defendant filed a Statement of 

Proposed Undisputed Facts. (Doc. 37, hereinafter “DPUF”). While the Standing Order of the Court 

requires parties to file statements of proposed undisputed facts to accompany motions for summary 

judgment, those rules pertain to motions filed pursuant to Federal Rule of Civil Procedure 56. Yet 

motions for judgments on the administrative record are “not contemplated by the Federal Rules of Civil 

Procedure.” Zurndorfer v. Unum Life Ins. Co. of Am., 543 F. Supp. 2d 242, 255 (S.D.N.Y. 2008). 

Therefore, under the Standing Order of the Court, parties are not required to file statements of proposed 

undisputed facts in support of motions for judgment on the administrative record. Nevertheless, the 

Court’s statement of facts references Defendant’s Statement of Proposed Undisputed Facts that are 

undisputed by the parties and confirmed by the Court upon review of the citations to the administrative 

record. The administrative record was filed by Defendant Anthem (Doc. 35), and references to the 

administrative record will be referred to by the Bates numbers.

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hospitalization, also means that safe and adequate care could not be obtained in a less 

comprehensive setting);” (6) cost-effective compared to alternative interventions; (7) not 

Experimental/Investigative; (8) not primarily for the convenience of the Member; and (9) 

not otherwise excluded. (AG_ANTHEM_000116–17). The Plan states that the “fact that 

a Provider may prescribe, order, recommend, or approve care, treatment, services or 

supplies does not, of itself, make such cares, treatment or supplies Medically Necessary 

or a Covered Service and does not guarantee payment.” (AG_ANTHEM_000117). 

The Plan grants Anthem “complete discretion to determine the administration of 

[Members’] benefits.” (AG_ANTHEM_000112). Anthem’s discretion includes 

“whether the services, care, treatment, or supplies Medically Necessary” and “all 

questions arising under the Certificate. (AG_ANTHEM_000112–13). In determining 

whether services are Medically Necessary, Anthem uses “clinical coverage guidelines, 

such as medical policy, clinical guidelines, and other applicable policies and procedures 

to assist in making [its] Medical Necessity decisions.” (AG_ANTHEM_000090). 

The Plan includes a Utilization Review process to determine whether services are 

Medically Necessary. The Certificate provides:

Utilization Review aids the delivery of cost-effective health care by 

reviewing the use of treatments and, when proper, level of care and/or the 

setting or place of service that they are performed. A service must be 

Medically Necessary to be a Covered Service. When level of care, setting 

or place of service is part of the review, services that can be safely given to 

you in a lower level of care or lower cost setting / place of care, will not be 

Medically Necessary if they are given in a higher level of care, or higher 

cost setting / place of care.

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Certain Services must be reviewed to determine Medical Necessity in order 

for you to get benefits. Utilization Review criteria will be based on many 

sources including medical policy and clinical guidelines. Anthem may 

decide that a service that was asked for is not Medically Necessary if you 

have not tried other treatments that are more cost effective.

(AG_ANTHEM_000088). 

As part of the Utilization Review, Anthem offers Pre-service Review, 

Precertification, Continued Stay / Concurrent Review, and Post-service Review. 

(AG_ANTHEM_000089). Pre-service Review is “[a] review of a service, treatment or 

admission for a benefit coverage determination which is done before the service or 

treatment begins or admission date.” (Id.). Precertification is “[a] required Pre-service 

Review for a benefit coverage determination for a service or treatment” that “will include 

a review to decide whether the service meets the definition of Medical Necessity” under 

the Certificate. (Id.). “Certain services require Precertification in order for [the insured] 

to get benefits.” (Id.). The Plan also offers urgent reviews, which “are conducted under a 

shorter timeframe than standard reviews,” where appropriate. (Id.).

When receiving treatment from a Non-Network Provider, Members must get 

Precertification when required. (AG_ANTHEM_000090). The Plan directs Members to 

contact Anthem “to be sure that Prior Authorization and/or precertification has been 

obtained.” (AG_ANTHEM_000077). When services are rendered by a Non-Network 

Provider and a Member has not received Precertification or Pre-service Review, the 

insured is responsible for “[s]ervices that are not Medically Necessary[.]” 

(AG_ANTHEM_000079, 90).

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The Plan provides benefits for behavioral/mental health Covered Services at 

different levels of care, including “Inpatient Services,” “Residential Treatment,”

“Outpatient Services” like “Partial Hospitalization Programs” and “Intensive Outpatient 

Programs,” and “Online Visits.” (AG_ANTHEM_000026). 

Residential Treatment must be provided in a licensed “Residential Treatment 

Center” that offers individualized and intensive treatment that includes observation and 

assessment by a physician weekly or more often and rehabilitation, therapy, and 

education. (Id.). The Plan defines a Residential Treatment Center as:

A Provider licensed and operated as required by law, which 

includes:

1. Room, board and skilled nursing care (either an RN or 

LUN/LPN) available on-site at least eight hours daily with 24 

hour availability;

2. A staff with one or more Physicians available at all times.

3. Residential treatment takes place in a structured facilitybased setting.

4. The resources and programming to adequately diagnose, 

care and treat a psychiatric and/or substance use disorder.

5. Facilities are designated residential, subacute, or 

intermediate care and may occur in care systems that provide 

multiple levels of care.

6. Is fully accredited by The Joint Commission (TJC), the 

Commission on Accreditation of Rehabilitation Facilities 

(CARF), the National Integrated Accreditation for Healthcare

Organizations (NIAHO), or the Council on Accreditation 

(COA). 

(AG_ANTHEM_000121–22).

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Regarding types of Outpatient Services, a Partial Hospitalization Program is 

defined as “[s]tructured, short-term behavioral health treatment off that offers nursing 

care and active treatment in a program that operates no less than 6 hours per day, 5 days 

per week.” (AG_ANTHEM_000118). An Intensive Outpatient Program is defined as 

“[s]hort-term behavioral health treatment that provides a combination of individual, 

group and family therapy.” (AG_ANTHEM_000116).

During the relevant time period, Anthem Used Clinical UM Guideline CG-BEH03H (the “Guideline”)5 to assist in determining “medical necessity for levels of care 

relating to psychiatric disorder treatment.” (AG_ANTHEM_001031–47). The Guideline 

provides the following criteria for Residential Treatment Centers:

Residential treatment center is considered medically necessary when the 

member has all of the following:

A. The Member is manifesting symptoms and behaviors which represent a 

deterioration from the Member’s usual status and include either self 

injurious or risk taking behaviors that risk serious harm and cannot be 

managed outside of a 24 hour structured setting or other appropriate 

outpatient setting; and

B. The social environment is characterized by temporary stressors or 

limitations that would undermine treatment that could potentially be 

improved with treatment while the member is in the residential facility; 

and

C. There should be a reasonable expectation that the illness, condition or 

level of functioning will be stabilized and improved and that a short 

term, subacute residential treatment service will have a likely benefit on 

5 The Guideline includes a list of references upon which it is based, including two peer reviewed 

publications, and eight government agency, medical society, and other publications, including, relevantly, 

the American Academy of Child & Adolescent Psychiatry, the American Psychiatric Association, the 

American Society of Addiction Medicine, the Association for Ambulatory Behavioral Health Care, and 

the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.). (See AG_ANTHEM_001044–45).

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the behaviors/symptoms that required this level of care, and that the 

member will be able to return to outpatient treatment; and

D. Member’s clinical condition is of such severity that an evaluation by 

physician or other provider with prescriptive authority is indicated at 

admission and weekly thereafter.

(AG_ANTHEM_001032–33).

The Guideline includes several criteria for whether a Partial Hospitalization 

Program is Medically Necessary, including the following:

The [M]ember is not imminently dangerous to self or others and is able to 

exercise adequate control over his/her behavior to function outside of 24 

hour custodial care. However, the member may exhibit some identifiable 

risk for harm to self or others yet is able to develop and practice a safety 

plan with the structured intensive support of PHP treatment.

(AG_ANTHEM_001033–34). 

The Guideline includes several criteria for whether an Intensive Structured 

Outpatient Program (“IOP”) is Medically Necessary, including “the clear potential to 

regress further without specific IOP services,” and “[t]he need for direct monitoring less 

than daily but more than weekly[.]” (AG_ANTHEM_001034–35). 

B. A.G.’s Treatment

A.G. struggled for years with mental health issues such as depression, anxiety, 

eating disorders, suicide ideations, and drug use. (Doc. 1 at ¶ 10). In December 2016, 

after a breakup with her boyfriend, A.G. cut her left forearm and sent a picture of her 

forearm to her ex-boyfriend. (DPUF at ¶ 24). A.G. stated that “she was using the selfharm to get her boyfriend’s attention. (Id.). 

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1. Ridgeview

The next day, A.G. was admitted to Ridgeview Institute (“Ridgeview”), a private 

hospital treating patients with addiction and mental health problems. (Id.) While at 

Ridgeview, A.G. “worked on developing triggers that have led to impulsive and 

unhealthy behaviors.” (AG_ANTHEM_000711). Providers at Ridgeview reported that 

A.G. was able to “process what coping skills would be beneficial in helping [her] abstain 

from giving into impulses.” (Id.). A.G. was discharged from Ridgeview on January 6, 

2017. (Id.). In A.G.’s discharge recommendations, her case manager provided “the 

strong recommendation for [A.G.] to enter outpatient therapy with a therapist on a 

weekly basis,” and “outpatient therapy with a psychiatrist so he/she can manage all 

medication and symptoms on a monthly basis.” (Id.).

2. Blue Ridge

On the day she was discharged from Ridgeview, A.G. enrolled at Blue Ridge. (Id. 

at ¶ 27). A.G. obtained treatment at Blue Ridge from January 6, 2017 through March 30, 

2017. (Id.). 

On February 17, 2017, Blue Ridge prepared a psychological assessment report for 

A.G. (Id. at ¶ 28). In the assessment, A.G. stated that she has “struggled with

depression” since she was 15, she had some self-harming behavior that began when she 

was 15 years, but she had not engaged in any self-harming behaviors for one year prior to 

the December 2016 incident. (Id. at ¶ 29). A.G. reported that “she is dedicated to 

schoolwork and has maintained good grades” and “describes herself as very confident in 

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herself and her abilities.” (Id. at ¶ 28). Additionally, her mother reported that A.G. was 

“likeable, charming,” “has a great work ethic, [and] is dedicated to school.” A.G. denied 

that she had any traumatic events in her life, or that she had any history of physical, 

sexual, or emotional abuse. (Id. at ¶ 31). A.G. denied “having a history of obsessive 

thoughts, compulsive behaviors, racing thoughts, homicidal thoughts, manic episodes, 

hallucinations, paranoia, grandiose ideations, or eating-disordered behaviors.” (Id.). 

Regarding substance abuse, the assessment states that A.G. “identified emotional and 

social triggers and risk factors related to drug and alcohol relapse.” (Id. at ¶ 36). 

Additionally, the assessment stated that A.G. “remained drug and alcohol free during her 

stay in Blue Ridge’s program” and “expresses a desire to remain abstinent from drugs 

and alcohol in the future.” (Id.) The assessment also found that A.G. had improved “in 

her ability to appropriately and assertively communicate with her parents, and to have 

healthier interactions.” (Id. at ¶ 37).

In Blue Ridge’s discharge recommendations, a clinician found that A.G. “was 

genuinely motivated to make progress at Blue Ridge[.]” (AG_ANTHEM_000715). Yet 

the clinician noted that she “remain[ed] very concerned regarding her risk for relapsing in 

the areas of conduct problems, social difficulties, depressive symptoms, anxiety, 

substance abuse if she were to return to her home environment after completing [Blue 

Ridge’s] program.” (Id.). The clinician “strongly recommended” that A.G. “go directly 

from Blue Ridge to her next placement.” She stated that “[r]eturning home, even for a 

few days, would place [A.G.] at great risk for a regression in functioning and would undo 

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much of the progress that she has made at Blue Ridge[.]” (Id.). A Blue Ridge clinical 

psychologist also stated that if A.G. “does not receive additional treatment, the potential 

for these problems to become worse is significant.” (AG_ANTHEM_000709).

3. Sunrise

A.G. was admitted to Sunrise on March 30, 2017, the same day she left Blue 

Ridge. (DPUF at ¶ 39). Sunrise, a residential treatment center in Hurricane, Utah, is a 

Non-network Provider under the Plan. (Id.). Plaintiff did not seek precertification of 

benefits at Sunrise for A.G. prior to her admission to Sunrise. (Id.). 

On April 3, 2017, a psychiatric evaluation for A.G. was completed by a Sunrise 

psychiatrist. (Id. at ¶ 41). Regarding A.G.’s mental status, the psychiatrist wrote:

She is pleasant, dressed appropriately, looks her stated age, denies suicidal 

ideation or self harm thoughts, has some feelings of hopelessness and 

helplessness, does feel ok being at Sunrise, thoughts are organized, logical 

and goal directed, no delusional thinking, denies auditory and visual 

hallucinations, oriented x 4, memory intact for recent and remote, 

appropriate responses to similarities and proverbs, intellectual level 

estimated to be in the high normal area, judgment is good, insight is 

present.

(AG_ANTHEM_000741). The psychiatrist diagnosed A.G. with “Major Depression, 

Polysubstance Use Disorder.” (Id.). The psychiatric evaluation included the plan to taper 

A.G. off of her medications. (Id.). 

On April 12, 2017, a Sunrise social worker completed a psychosocial assessment 

on A.G. (AG_ANTHEM_000721). The psychosocial assessment stated that the reason 

for referral/presenting problems was A.G.’s “[r]elapse of self-harming behaviors, use of 

substances including meth, depression, anxiety, excessive shame thoughts.” (Id.) A.G.’s 

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parents’ expectations for treatment was reported as “wanting [A.G.] to build self-worth, 

and be comfortable with herself. They want her to see how she does not need friends to 

have self-worth.” (Id.). A May 1, 2017, a psychiatric note stated that A.G. “seems to be 

doing quite well” and wanted to taper off her antipsychotic medication. 

(AG_ANTHEM_000719). The psychiatric note further states that A.G. “looks good 

today, mood seems stable, affect is appropriate, denies self harm thoughts, has been at 

Sunrise about 45 days and feels that it is a good fit for her.” (Id.)

Sunrise created a Master Treatment Plan for A.G on May 1, 2017. (DPUF at 

¶ 44). The treatment plan diagnosed A.G. with “Major Depressive Disorder, Recurrent, 

Moderate,” “Generalized Anxiety Disorder with Panic Attacks,” “Cannabis Use Disorder, 

mild, in a controlled environment,” “Substance Use Disorder, in early remission,” and 

“Parent-child relational problem.” (AG_ANTHEM_000734). The Master Treatment 

Plan listed several objectives for A.G. to address her depression, anxiety, and substance 

abuse. (AG_ANTHEM_000734–37). A treatment team note entered on April 27, 2017, 

before the Master Treatment Plan was issued, listed the nine objectives as “ongoing.” 

(AG_ANTHEM_000726–31). An August 31, 2017 treatment team note stated that A.G. 

had completed her first objectives for her depression, anxiety, and substance use on 

August 9, 2017. (AG_ANTHEM_000724–25). A September 28, 2017 treatment team 

note reported that A.G. had competed her second objectives for her depression, anxiety, 

and substance abuse on September 10, 2017. (AG_ANTHEM_000722–23).

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C. Benefits Determination

On March 31, 2017, Anthem received Plaintiff’s initial benefits request for A.G.’s 

treatment at Sunrise from March 30, 2017 to April 12, 2017. (ANTHEM_AG_000425–

26, 435). To review A.G.’s benefits claim, Anthem UM Services, Inc. (“Anthem 

UM”)—which provides utilization management services for Anthem—engaged Dr. 

Charlisa Allen, M.D., a board-certified psychiatrist. (Id., AG_ANTHEM_000890–91). 

In conducting the review of A.G.’s claim, Dr. Allen reviewed A.G.’s psychiatric 

treatment history and conducted a telephonic conference with the attending physician at 

Sunrise on April 4, 2017. (AG_ANTHEM_000890–91). Dr. Allen found that A.G.’s 

treatment at Sunrise was not Medically Necessary because she “does not have severe 

medical issues or severe risky, agresssive [sic], or threatening psychiatric issues which 

would require 24 hr [residential treatment center] level of care” and that her “[m]ental 

health symptoms were not severe[.]” (Id.). Dr. Allen further found that A.G. did not 

exhibit psychosis or self-harm ideation, and was not suffering from any substance abuse 

issues because of her multi-month stay in a wilderness program. (Id.). Dr. Allen further 

noted that the treatment A.G. was receiving at Sunrise could be provided in a Partial 

Hospitalization Program—which is a lower level of care than a Residential Treatment 

Center—but Sunrise declined. (Id.). Based on these findings, Dr. Allen recommended 

denying coverage as not Medically Necessary. (Id.). 

On April 5, 2017, Anthem UM submitted a letter denying coverage for A.G.’s 

requested benefits for her treatment at Sunrise from March 30, 2017 to April 12, 2017, 

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finding that the treatment was not Medically Necessary under the Plan. The letter was 

sent to A.G.; Dr. Cantril, a physician at Sunrise; and the insurance verifier at Sunrise of 

Anthem’s benefit determination. (AG_ANTHEM_000425–29, 509–13, 518–22). The 

first page of the letter states:

Based on the review of the information provided to us, the service 

referenced above is not medically necessary, as that term is defined under 

your health benefit plan. Services which are not medically necessary are a 

benefit exclusion and therefore not a covered benefit.

The second page of the letter6 states that Anthem’s physician consultant concluded 

the following:

A request was made for you to receive residential treatment for your mental 

health condition. The plan criteria considers short-term residential 

treatment medically necessary for those who meet all the following: 1) their 

behaviors have worsened and risk serious harm to themselves or others; 2) 

the behaviors or actions cannot be managed outside of a 24 hour structured 

setting; 3) their living situation keeps them from getting needed treatment; 

and 4) improvement can be expected from a short-term residential stay. 

The information we have does not show your behavior is putting you at risk 

for serious harm or 24 hour structured care is needed. For those reasons, 

the request is denied as not medically necessary. There may be other 

treatment options to help you, such as partial hospital or intensive 

outpatient services. You may want to discuss these with your doctor. It 

may help your doctor to know we reviewed the request using the plan 

clinical guideline called Psychiatric Disorder Treatment Residential Center 

(RTC) CG-BEH-03.

(AG_ANTHEM_000426, 510, 519; see also AG_ANTHEM_000892).

6 Plaintiff contends that there is no evidence that A.G. ever received the second page of the letter that is 

included in the Administrative Record, which contains information behind Anthem’s denial. (Doc. 38-1 

at 4–5). Yet the Court need not weigh in on whether or not Plaintiff received the second page of the 

denial letter because, as Defendant notes, Plaintiff has not alleged that Anthem failed to provide a full and 

fair review of Plaintiff’s claim. (Doc. 39 at 8). Moreover, it is not in dispute that the second page of the 

denial letter reflects the findings of Dr. Allen that A.G.’s treatment at Sunrise was not medically 

necessary, which is the core issue in this matter. (AG_ANTHEM_000890–92). 

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On October 4, 2017,7 Patricia Gish, from the Mental Health Autism Insurance 

Project, submitted a level one appeal of Anthem’s benefit determinations for A.G.’s 

Residential Treatment. (AG_ANTHEM_001048–61). In accordance with the Plan, 

Anthem engaged Dr. Jessica Chaudhary, a board-certified psychiatrist, to review A.G.’s 

claim. (AG_ANTHEM_000449, 892). In her review, Dr. Chaudry noted that A.G. had 

improved considerably during her time at Blue Ridge, but the Blue Ridge physicians 

believed that residential treatment was necessary for ongoing chronic, passive suicidal 

ideation. (AG_ANTHEM_000892). Dr. Chaudry emphasized that there was no noted 

active suicidal ideation, no aggression or agitated behaviors, and that A.G.’s family was 

involved. (Id.). For those reasons, Dr. Chaudry concluded that A.G.’s treatment could 

have safely occurred at a lower level of care, and therefore concluded that A.G.’s 

treatment was not a Covered Service because it was not Medically Necessary. (Id.). 

On October 30, 2017, Anthem UM sent a letter to A.G. upholding the denial of 

benefits for A.G.’s residential treatment at Sunrise. (ANTHEM_AG_000881–89). The 

letter stated: 

We reviewed all the information that was given to us before with the first 

request for coverage. We also reviewed all that was given to us for the 

appeal. Your doctor wanted you to have residential treatment center care. 

The reason we were given for this was that you were at risk for serious 

harm without 24 hour care. We understand that you would like us to change 

our first decision. Now we have new information from the medical record. 

We still do not think this is medically necessary for you. We believe our 

first decision is correct for the following reason. You were not at risk for 

7 Plaintiff states that her appeal was submitted on September 28, 2017 (Doc. 38-1 at 5), yet the 

Administrative Record reflects that the appeal was submitted on October 4, 2017. (AG_ANTHEM_

001243). Defendant notes that it “processed the appeal, even though the appeal may have been 

untimely.” (Doc. 39 at 8).

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serious harm that you needed 24 hour care. You could have been treated 

with outpatient services.

(AG_ANTHEM_000881–82).

After Anthem upheld the denial of benefits for A.G.’s residential treatment at 

Sunrise, A.G. had fully exhausted the Plan’s internal appeal process. Subsequently, 

Plaintiff filed this action challenging Defendant’s denial of benefits.8

III. STANDARD OF REVIEW

This Court reviews de novo a denial of benefits under an ERISA plan “unless the 

benefit plan gives the plan administrator discretionary authority to determine eligibility 

for benefits or to construe the terms of the plan.” Univ. Hosps. v. Emerson Elec. Co., 202 

F.3d 839, 845 (6th Cir.2000) (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 

115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989)). If an administrator has such discretionary 

authority, the Court reviews the denial of benefits under the arbitrary and capricious 

standard. Firestone, 489 U.S. at 111.

As the Court noted in its Order on Defendant’s partial motion to dismiss, “it is 

undisputed that Anthem had full discretionary authority to interpret the Plan.” (Doc. 16 

at 8). Thus, the arbitrary and capricious standard applies.

Therefore, Plaintiff “bears the burden of proving that the Plan Administrator's 

decision was arbitrary or capricious; otherwise, the decision of the Plan Administrator 

8 On January 22, 2018, Anthem also sent Plaintiff a letter denying a request for benefits at Sunrise for 

dates of service between October 1, 2017 and November 2, 2017. (AG_ANTHEM_000417–24). Anthem 

rejected Plaintiff’s request for her treatment at Sunrise over this time period finding, again, that the 

services were not Medically Necessary.

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‘must be sustained as a matter of law.’” Farhner v. United Transp. Union Discipline 

Income Prot. Program, 645 F.3d 338, 343 (6th Cir. 2011) (quoting Gardner v. Central 

States, Se. and Sw. Areas Pension Fund, et al., 14 F.3d 601 (table), No. 93–3070, 1993 

WL 533540, at *3 (6th Cir. Dec. 21, 1993)). In determining whether the administrator’s 

decision was arbitrary and capricious, the Court “may consider only the evidence 

available to the administrator at the time the final decision was made.” McClain v. Eaton 

Corp. Disability Plan, 740 F.3d 1059, 1064 (6th Cir. 2014).

Nonetheless, merely because the review is deferential does not mean that the court 

must rubber-stamp the administrator's decisions. McDonald v. Western–Southern Life 

Ins. Co., 347 F.3d 161, 172 (6th Cir.2003). The administrator's decision must be upheld, 

however, if “the record evidence offers a reasoned explanation for the decision.” 

Mechley v. Proctor & Gamble, No. C–1–06–538, 2008 U.S. Dist. LEXIS 116306, at *5, 

2008 WL 2796728 (S.D. Ohio July 17, 2008) (citing Davis v. Kentucky Fin. Cos. Ret. 

Plan, 887 F.2d 689, 693 (6th Cir.1989)). “Even if the Court would not have come to the 

same conclusion as the Plan Administrator, as long as there is a reasonable basis for the 

decision, it must be upheld.” Moon v. Unum Provident Corp., 405 F.3d 373, 379 (6th 

Cir. 2005).

IV. ANALYSIS

The issue before the Court is simple: whether Anthem’s determination that 

Plaintiff’s treatment at Sunrise was not Medically Necessary was arbitrary and 

capricious. Based on the Administrative Record, it is clear that Anthem’s benefits denial 

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was not arbitrary and capricious.

The Court must uphold Anthem’s benefits denial as long as the record evidence 

offers a reasoned explanation for its denial. Here, Anthem contends that its finding that 

Residential Treatment was not Medically necessary was supported by 1) A.G.’s treating 

provider at Ridgeview recommending that she enter outpatient therapy, a lower level of 

care than residential treatment; 2) A.G.’s providers at Blue Ridge and Sunrise 

recognizing that A.G. was improving throughout her treatment; and 3) two boardcertified psychiatrists separately concluding that A.G. could safely be treated at a lower 

level of care than residential treatment. (See Doc. 39 at 9–10). 

Plaintiff contends that Anthem’s decision was arbitrary and capricious because 

A.G.’s treating physicians at Blue Ridge and Sunrise both found 24-hour residential 

treatment for A.G. was Medically Necessary.9

 (Doc. 38-1 at 8–13). However, the “fact 

that a Provider may prescribe, order, recommend, or approve care, treatment, services or 

supplies does not, of itself, make such cares, treatment or supplies Medically Necessary 

or a Covered Service and does not guarantee payment.” (AG_ANTHEM_000117). 

While providers at Blue Ridge and Sunrise did consider Residential Treatment to be 

Medically Necessary, providers at Ridgeview did not. Tellingly, Plaintiff completely 

9 The primary case Plaintiff relies on, Shaw v. AT&T Umbrella Benefit Plan No. 1, 795 F.3d 538 (6th Cir. 

2015), is largely inapposite. Shaw relates to a plan administrator’s benefits determination regarding a 

disability claim, which is a different analysis than a mental health claim. 795 F.3d at 547. Moreover, the 

Court is persuaded by Defendant’s brief that Shaw is also factually distinguishable from this case. (See 

Doc. 39 at 13–15). 

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ignores that A.G.’s case manager at Ridgeview recommended that A.G. at an outpatient 

facility, not a residential treatment center. 

Ridgeview’s determination that A.G. should be treated at a lower level of care 

than a Residential Treatment Center is itself virtually dispositive, as it shows that 

Anthem’s determination was not arbitrary and capricious because Anthem was relying on 

the medical opinions of A.G.’s providers. See Brown v. Fed. Exp. Corp., 610 F. App’x 

498, 505 (6th Cir. 2015) (“[W]hen a plan administrator chooses to rely upon the medical 

opinion of one doctor over that of another in determining whether a claimant is entitled to 

ERISA benefits, this decision cannot be said to have been arbitrary and capricious 

because it would be possible to offer a reasoned explanation, based upon the evidence, 

for the plan administrator’s decision.”). Nevertheless, if Plaintiff could point to evidence 

that A.G.’s condition deteriorated after Ridgeview recommended a lower level of care, 

then Anthem’s reliance on the Ridgeview providers’ findings could potentially be

construed as arbitrary and capricious. But that is not the case. Here, there Administrative 

Record reflects— and Plaintiff concedes (see Doc. 38-1 at 9–11) — that A.G. continued 

the progress she made at Ridgeview during her time at both Blue Ridge and Sunrise. 

Therefore, because it was reasonable—based on substantial evidence in the record—to 

conclude that A.G.’s symptoms and behaviors were not deteriorating and that A.G. could 

have been safely treated at a lower level of care, Anthem did not arbitrarily and 

capriciously conclude that A.G.’s treatment at a Sunrise was not Medically Necessarily. 

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Accordingly, Defendant’s motion for judgment on the administrative record is welltaken, and Plaintiff’s motion fails as a matter of law.

V. CONCLUSION

For the foregoing reasons, 

1) Defendant’s motion for judgment on the administrative record (Doc. 36) is 

GRANTED.

2) Plaintiff’s motion for judgment on the merits (Doc. 38) is DENIED.

3) The Clerk shall enter judgment accordingly, whereupon this case is 

TERMINATED from the docket of this Court.

IT IS SO ORDERED.

Date: 11/30/2020 /s/ Timothy S. Black

Timothy S. Black

United States District Judge

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