UNITED STATES COURT OF APPEALS FOR THE TENTH CIRCUIT

________________ _________________ TRACY O. and DANTE O., individually and as guardians of S.O., a minor, Plaintiffs–Appellants,

v. ANTHEM BLUE CR OSS LIFE AND HEALTH INSURANCE; ANTHEM UM SERVICES, INC., Defendan t –Appellee. No. 17-4135 (No. 2:16-CV-00422-DB) (D. Utah)

________________ _________________ ORDER AND JUDGMENT 

________________ _________________ Before BRISCOE, BALDOCK , and EID , Circuit Judges.

________________ _________________ Appellants Dante O. and Tracy O. were enrolled in a health benefits plan insured by Appellees Anthem Blue Cross Life and Health Insurance Company and administered by Anthem UM Services, Inc. (together, An them). The plan 1 only covered psychiatric treatment that Anthem determined to be “medically necessary.” Dante O. and Tracy O. sent their daughter, S. O., to a residential psychiatric treatment

 This order and judgment is not binding precedent, except under the doctrines of law of the case, res judica ta, and collateral estoppel. It may be cited, however, for its persuasive value consiste nt with Fed. R. App. P. 32.1 and 10th Cir. R. 32.1. 1 As explained more in-depth in Secti on II.A, we consider “the plan” to be both the Combined Evidence of Coverage a nd Disclosure form and the Group Benefit Agreement documents presented in the administrative record. FILED United States Court of Appeals Tenth Circuit 

### April 3, 2020 Christopher M. Wolpert Clerk of Court2 center for ten months to a ddress her significant mental health problems. Anthem determined that residentia l psychiatric treatment was not medically necessary for S.O. and denied coverage. After exhaus ting administrative remedies, Dante O. and Tracy O. sued Anthem. The district c ourt granted summary judgment to Anthem, holding that the adverse hea lth benefits decision passed muster under either an arbitrary and capricious or de novo review. The language of the plan provides that “ THE BENEFITS OF THIS PLAN ARE PROVIDED ONLY FOR THOSE SERVICES THAT WE DETERMINE TO BE MEDICALLY NECESSARY .” Our court’s reasoning in Eugene S. v. Horizon Blue Cross Blue Shield of N.J. , 663 F.3d 1124, 1131 (10th Cir. 2011), dictates that a health benef its plan “grants discretion to the plan administrator in reviewing benefits claims” when the “plan language” gives discretionary authority to a plan administrator. See, e.g. , id. at 1132 (entrusting the “medically necessary” determination to the administ rator). We conclude the pl an in this case gives such discretion to Anthem, and that its decision to deny residential c overage stands unless it is arbitrary and capricious. We conclude that such a showing has not been made, and thus affirm the dist rict court’s judgment.
I. Dante O.’s employer, California Co mmerce Club, Inc., provided a fullyinsured employee group health benefits plan governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. §§ 1001–1461. Anthem Blue Cross is the insurer of the plan, and Anthem UM Services , Inc. handles plan cl aims and appeals.3 The two plan documents that have been produced are the Combined Evidence of Coverage and Disclosure form (Evidence of Coverage form) and the Group Benefit Agreement. See App. 182 (Order at 5); see also id. at 191 n.6 (Order at 14 n.6). 2 According to those documents , Anthem will pay for psychi atric treatment that is “medically necessary,” id. at 182 (Order at 5), and An them makes the determination of medical necessity. Indeed, unde r the Evidence of Coverage form, “ THE BENEFITS OF THIS PLAN ARE PROV IDED ONLY FOR THOSE SERVICES THAT WE DETERMINE TO BE MEDICALLY NECESSARY .” Id

. Residential psychiatric treatment—treatme nt at a “24 hours per day” facility with at least one doctor visit per week, id. at 183 n.3 (Order at 6 n.3)—qualifies for coverage under the plan if three criteria are met:
1. The Covered Individual is manifest ing symptoms and behaviors which represent a deterioration from their [s ic] usual status and include either self injurious or risk taking beha viors that risk serious harm and cannot be managed outside of a 24 hour structured setting. 2. The social environment is charact erized by temporary stressors or limitations that would undermine treat ment that could potentially be improved with treatment while the Covered Individual is in the residential facility. 3. There should be a reasonable expecta tion that the illness, condition or level of functioning will be stabili zed and improved a nd that a short term, subacute residential treatment service will have a likely benefit

2 The parties initially designated a signifi cant portion of the appendix be sealed for the protection of sensitive medical inform ation. Upon order of this court, the parties agreed to unseal a ll documents that did not contain personal health information or had been previously discusse d by the parties in their briefing or by the district court. The parties ha ve also agreed to file a redacted version of the Group Benefit Agreement. We theref ore do not cite to, or quote, anything here that is not contained in the now-unsealed portions of the appendix or quoted by the parties in their unsealed briefing or the dist rict court in its opinion below.4 on the behaviors/symptoms that requi red this level of care, and that the Covered Individual will be able to return to outpatient treatment. Id. at 183 (Order at 6). After years of medical issues, includi ng diagnoses of ge neralized anxiety disorder, major depressive disorder, bor derline personality tendencies, bulimia nervosa, obsessive-compulsi ve disorder, and autism sp ectrum disorder, S.O. was admitted to New Haven Residentia l Treatment Center in Utah. Id. at 181 (Order at 4). S.O. lived at New Haven for ten months. Aple. Br. at 19. Early in her time at New Haven, Dr. Rick Biesinge r psychologically evaluated S.O., stating that at the time she “denied having any suicid al ideation.” App. 181 (Ord er at 4). S.O. initially told Dr. Biesinger she cut he rself once a day, but eventua lly explained the last time she did so was “two months ago.” Id. A few days after S.O.’s admission to New Haven, Dante O. and Tracy O. asked Anthem to certify th at S.O.’s care was covered by the plan by seeking a preauthorization. Dr. Richard Co ttrell, a psychiatrist, determin ed that S.O. did not meet the requisite criteria for resi dential treatment but could be treated at an outpatient facility. Id. at 185 (Order at 8). Anth em denied coverage becau se it determined that the service was not “medic ally necessary” based on th e information Anthem had received from the service provider and the recommendation of Anthem’s evaluating physician, Dr. Timothy Jack. Id. at 184 (Order at 7). An them’s medical reviewer, Dr. Marina Bussel, echoing Dr. Cottrell, explained: “You went to this program because your behavior could be harmful to yourself or ot hers. You have not caused serious harm to anyone. Y ou have not harmed yourself to such a degree that has5 caused serious medical problems. You have not had recent treatment for this in a structured outpatient program . You are also likely to benefit from structured outpatient treatment.” Id. at 185 (Order at 8)

. Dante O. and Tracy O. appealed Anthem’s denial of coverage. To substantiate the medical necessity of S. O.’s treatment at New Have n, Dante O. and Tracy O. submitted a letter by Dr. Linda Woodall, S.O.’s treating psychiatrist . Aplt. Br. at 20. The letter reads, in part: [S.O.] had had a previous psychiatrist at age 6 years old for lability and OCD. As her disorder progressed, however, she began to have clear psychotic symptoms with and w ithout severe mood swings. She exhibited dangerous beha vior: binge eating, purging, restricted eating, severe weight loss, cutting, and hype rsexuality. . . . Unfortunately, she became frankly psychotic by 3/24/11, with suicidal ideation . . . This is clearly a very disturbe d young woman who has been difficult to manage, both medically and behaviorally , with traditional care. Her Schizoaffective disorder, bipolar t ype, dangerous beha vior, and eating disorder warrant long-ter m residential treatment. Id. at 20–21. Dante O. and Tracy O. also s ubmitted a letter by S.O. ’s therapist, Carol Maskin, who stated that S.O. “had too many tr iggers in her environment to be able to use the tools she learned in therapy. . . . [S]he was ex tremely symptomatic and on a daily basis there was concer n for her safety. . . . base d upon my experience of working with adolescents, it wa s clear to me that [S.O.] w ould only get worse or even succeed at suicide.” Id. at 21. Dr. Donald Mayes, an Anthem doctor, re viewed S.O.’s covera ge eligibility in light of Dante O. and Tracy O.’s appeal . App. 187 (Order at 10). Anthem maintained its denial, concluding, based in part on Dr. Mayes’ conclusions, that New6 Haven was not “medically necessary.” Id. at 188 (Order at 11). It noted S.O.’s problems “had been going on for some time ” and concluded that she “could be safely treated with outpatient services.” Id. Anthem notified Dante O. and Tracy O. its decision was “final,” and that their “grievance rights with [Anthem] are exhausted.” Id. Anthem’s letter also advised Dante O. and Tracy O. of their ability to seek an independent medical review fro m the California Department of Managed Health Care (DMHC). Id. Dante O. and Tracy O. requested the DM HC conduct an independent review of Anthem’s coverage denial. Id. In their letter to the DM HC, they argued that Anthem failed to meaningfully engage with their evidence and argum ents. Aplt. Br. at 22–23. The DMHC assigned the matter to MAXI MUS Federal Services , Inc., a private contractor that reviews adverse health bene fits decisions. App. 188 (Order at 11). MAXIMUS upheld Anthem’s de termination that residentia l treatment at New Haven was not medically necessary. Id. at 189 (Order at 12). Specifically, MAXIMUS concluded that, prior to ad mission at New Haven, ther e was no evidence that S.O. “was actively suicidal with in tent or plan to harm hersel f during the period at issue.” Id. at 190 (Order at 13). Therefore S.O. “did not require 24-hour supervision in a residential setting and could have safely been treated at a lower level of care.” Id. Dante O. and Tracy O. sued Anthem unde r ERISA, which provides for judicial review of benefits determin ations. 29 U.S.C. § 1132(a)(1 )(B). Both parties moved for summary judgment. The district court determined the “Group Benefit Agreement,” and by incorporation the “Combined Evidence of Coverage and7 Disclosure Forms,” “constitute the plan documents in th is case.” App. 191 n.6 (Order at 14 n.6). The district court gr anted Anthem’s motion and denied Dante O. and Tracy O.’s motion, see id. at 178–97 (Order), because while there had been “some deterioration of S.O.’s symptoms,” the court reasoned th e deterioration was not beyond the behaviors S.O. had “cons istently” exhibited since middle school, id. at 193 (Order at 16). The court determin ed Anthem’s decisi on was entitled to deference and that the deni al of benefits was not “a rbitrary and capricious.” Id. at 194 (Order at 17). The court also conc luded Anthem’s decision would stand even under de novo review. Id. Dante O. and Tracy O. appeal ed. We first review whether Anthem’s denial of health bene fits is entitled to deferen ce and conclude that it is. We then review whether An them’s decision to deny S. O. residential treatment coverage was arbitrary and capri cious. We conclude it was not.
II. A. At the outset, we must determine wh ich documents compri se the governing plan in this case. The ad ministrative record contains the two documents Anthem produced below: the Group Benefit Agreemen t and the Evidence of Coverage form. We agree with the district court’s conclusion that together both the Group Benefit Agreement and the Evidence of Cove rage form comprise the plan. Id. at 191 n.6 (Order at 14 n.6). First, we conclude that the Group Benefit Agreem ent is the governing plan instrument between the parties. App. 2767–83. Signed by the president and8 secretary of Anthem, the Group Benefit Ag reement bears all the hallmarks of a governing health insura nce contract. It lists the plan ’s effective date, states the conditions for contract acceptance and term ination, chooses to be governed by California law, explains how the agre ement can be amended, requires group beneficiaries to indemnify An them if unauthorized confid ential disclosu res are made, and addresses obligations arising from the Health Insuran ce Portability and Accountability Act (HIPAA). App. 2767–74 . The Group Benefit Agreement also defines the circumstances in which parole evidence can be used, and the effect of clerical errors on plan coverage. Id. Most importantly, the Group Benefit Agreement does not refer the reader to a different documen t for particular terms; rather, it states the plan’s “benefits are subject to all of the terms and conditions of this agreement .” Id. (emphasis added). The second document in the record that we consider is the Evidence of Coverage form, which provides the following: This Combined Evidence of Coverage and Disc losure (Evidence of Coverage) Form is a summary of the important terms of your health plan

. The health plan contract must be c onsulted to determine the exact terms and conditions of coverage . . . . Your employer w ill provide you with a copy of the health plan contract upon request.
App. 55 (emphasis added). The “summa ry” language suggests the Evidence of Coverage form serves as a summary plan de scription (SPD), and we treat it as such. Indeed, an SPD is a plain language explana tion of the “rights and obligations” given9 to plan beneficiaries. 29 U. S.C. § 1022(a). And that is precisely what the Evidence of Coverage form does in this case. Importantly, the Group Benefit Agreem ent incorporates the Evidence of Coverage form. In the section titled “General Provisions,” the Group Benefit Agreement states “[t]he entir e agreement consists of”:
1. these administrative pages, including any endorsements; 2. all Combined Evidence of Cover age and Disclosure Forms , including any amendments, which are made a part of this agreement; 3. the application of the group; and 4. the individual applications, if any, of eligible persons. App. 2769 (emphasis added and other italics removed). 3 Accordingly, the district court concluded the Group Benefit Agreemen t, and by incorporation the Evidence of Coverage form, “constitute the plan documents in this case.” App. 191 n.6 (Order at 14 n.6). We agree. The Group Benefit Agreement is the governing plan document, and its incorporation by refe rence of the Evidence of Coverage form renders both documents, read together, the plan in this case. Any doubt that the Group Benefit Agr eement can incorporate the Evidence of Coverage form as one of the plan documents is dispelled by Eugene S. There, this court held that when “the in surer . . . demonstrate[s] th at the SPD is part of the

3 Dante O. and Tracy O. argue th e Group Benefit Agreement was never “distributed to [p]lan partic ipants and beneficiaries.” Ap lt. Br. at 32. They do not cite any Tenth Circuit authority for this proposition. Moreover, there is no statutory duty under ERISA to “distribute” a plan; the statute states only that the SPD must be made “available.” 29 U.S.C. § 1024(b)(2) (“ The administrator sha ll make copies of the latest summary plan description . . . available for examination by any plan participant or beneficiary . . . .”). Id.10 [p]lan” by pointing to the text of the plan, the SPD is binding. Eugene S. , 663 F.3d at
1131–32. In Eugene S. , the court concluded the SPD was binding because the “Certificate of Coverage” listed the SPD as part of the enti re “Group Policy.” Id. at 1132. Under such circumstan ces, the SPD is not just about the plan, “it is the Plan.” Id. at 1131. Like the certificat e of coverage document in Eugene S. , here the Group Benefit Agreement incorporates an SPD, the Evidence of Coverage form. We recognize that, unlike in Eugene S. , the Evidence of Coverage form does not state it is part of the plan; instea d, the governing plan docum ent incorporates the SPD. Id. at 1131. However, we do not see this as being a meaningful distinction. If the SPD can make itself a part of the pl an, then the governing documen ts can incorporate the SPD. It is true that, as Dante O. and Tracy O. point out, the Evidence of Coverage form directs the reader to consult the “health plan c ontract” for “the exact terms.” App. 55. There is no document in the ad ministrative record la beled “health plan contract,” nor does the record contain an overarching master plan document. However, the parties have never disputed that a “health plan contract” was not produced below, and agree that a mast er plan document “does not exist.” See id. at 83 (Appellants’ summary-judg ment response arguing “it is undisputed in this case that a master [p]lan document does not exist and is not before the Court”); Aple. Br. at 26–28 (arguing no docum ents are missing from the administrative record). Significantly, Dante O. and Tracy O. have never argued, and do not argue before us, that the lack of an overarchi ng master plan document precludes review of11 their claim. Instead, they argue that the language in the Evidence of Coverage form does not provide for discretionary review , an argument that we reject below. As noted above, the administrative reco rd contains the two documents Anthem produced below, the Group Benefit Agreemen t and the Evidence of Coverage form. For the reasons stated above, we conclude that the two documents comprise the plan and that, in particular, the Evidence of Covera ge form is part of the plan because it is incorporated by reference in the Group Benef it Agreement. But ev en if the Evidence of Coverage form were just an SPD a nd not incorporated as a governing plan document, we would still be permitted to tr eat it as the plan if the parties have done so. As the Supreme Court explained in U.S. Airways v. McCutchen , where the parties “have treated the language from the summar y description as though it came from the plan, we do as well.” 569 U. S. 88, 92 n.1 (2013). Here, in noting the limited record, the parties have treated the Evidence of Coverage form, an SPD, as the governing document for all intents and purposes. For example, Dante O. and Tracy O. use the SPD’s definition of “medical necessity” in their briefing as the plan’s operative definition. See Aplt. Br. at 17 (citing App. 2169–70). And Anthem insists there is no other master plan document, but rather the Evidence of Cove rage form “is the governing plan document.” Aple. Br. at 26– 27. Because the par ties treat the SPD as the operative document, pursuant to McCutchen , so do we. 4 We therefore proceed to

4 Further, many of our sist er Circuits have concluded that where there is no other governing document available in the record, the SPD may be treated as the governing plan document. See Rhea v. Alan Ritchey, Inc. Welfare Benefit Plan , 858 F.3d 340 (5th Cir. 2017) (noting “when an SPD is a plan’s only plausible written12 address the merits of appellants’ case under th e terms of the plan, as articulated in the Group Benefit Agreement and the Evidence of Coverage form.
B. This court reviews de novo whether an ERISA plan delegates interpretative authority to the plan administrator. LaAsmar v. Phelps Dodge Corp. Life , 605 F.3d 789, 796 (10th Cir. 2010). A denial of benefits covere d by ERISA is reviewed de novo unless the benefits plan gives the plan administrator discretionary authority to determine eligibility for be nefits or to construe the terms of the plan. Eugene S. , 663 F.3d at 1131. Whether a health benefits plan “grants discretion to the plan administrator in reviewing benefits cl aims” turns on the “plan language.” See id. at 1132 (entrusting the “medical ly necessary” determinati on to the administrator); Nance v. Sun Life Assur. Co. of Can. , 294 F.3d 1263, 1267 (10t h Cir. 2002) (“Proof must be satisfactory to Sun Life”); McGraw v. Prudential Ins. Co. of Am. , 137 F.3d

instrument, courts assume that the SPD is the written instrument.”); Prichard v. Metro. Life Ins. Co. , 783 F.3d 1166, 1170 (9th Cir. 2015) (“ Amara ’s holding assumes the existence of both an SPD and a written plan instrument. That is Amara addressed only the circumstance where bot h a governing plan document and an SPD existed . . . It did not address th e situation . . . [where] th e SPD [was] the one and only formal plan document.”); Bd. of Trustees of the Nat. Elevator Indus. Health Benefit Plan v. McLaughlin , 590 F. App’x 154, 156 n.1 (3rd Cir. 2014) (unpublished) (citing U.S. Airways for the proposition the parties treate d the SPD as the plan throughout litigation); Bd. of Trustees of the Nat. Eleva tor Indus. Health Benefit Plan v. Montanile , 593 F. App’x 903, 909–11 (11th Cir. 2014) (unpublished) (“[T]he Amara Court had no occasion to consider whether the terms of a summar y plan description are enforceable where it is the only document that” specifies benefits), rev’d on other grounds by 644 F. App’x 984 (11th Ci r. 2016) (unpublished); see also Feifer v. Prudential Ins. Co. of Am. , 306 F.3d 1202, 1209 (2d Ci r. 2002) (holding an SPD published long in advance of the master pl an could serve as the plan “when it was the only document desc ribing benefits”).13 1253, 1256 (10th Cir. 1998) (granting administrato r authority to decide when treatment is “needed”); Chambers v. Family Health Plan Corp. , 100 F.3d 818, 825 (10th Cir. 1996) (e xcluding coverage for treatme nt the administrator deems “experimental”). To reiterate, the Evidence of Coverage fo rm states, in bold, all-capital letters,

“ THE BENEFITS OF THIS PLAN ARE PROVIDED ONLY FOR THOSE SERVICES THAT WE DETERMINE TO BE MEDICALLY NECESSARY .” App. 182 (Order at 5); see also id. at 191 (Order at 14) (“We will determine if services are medically necessary and appropriate.”). This plan language is nearly identical to the language we held as granting discretionary authority in Eugene S . In that case, this court found several instan ces of plan language sufficient to grant discretion, including: “Horizon BCBSNJ determines what is medically necessary and appropriate.” Eugene S. , 663 F.3d at 1132. Given that this court has been “comparatively liberal in construing language to trigger the more deferential standard of review under ERISA,” Nance , 294 F.3d at 1268, this language more than adequately grants discretionary authority to Anthem over benefits claims and triggers arbitrary and capricious review. 5

5 Whether the “medically n ecessary” proviso grants di scretion to Anthem does not get deference itself. Here, the proviso unambiguou sly grants deference to Anthem so contra proferentem (interpretation agains t the draftsman) is “inapplicable.” See Kimber v. Thiokol Corp. , 196 F.3d 1092, 1100–01 (10th Cir. 1999).14 Dante O. and Tracy O. argue Anthem’s “medically necessa ry” proviso does not convey discretionary authority to An them, but merely recognizes “the role insurers always play in ev aluating a claim.” Aplt. Br. at 35. That argument is inconsistent with Eugene S. , where this court held th at the language “‘Medically Necessary and Appropriate’ . . . [as] ‘determined by [t he plan administrator’s] medical director or designee(s)’” was suffi cient to grant the administrator discretion in reviewing benefits claims. Eugene S. , 663 F.3d at 1132. Thus, we must give deference to Anthem’s deni al of health benefits. 6
C. We now turn to our final issue: whethe r Anthem’s decision to deny S.O. health benefits was arbitrary and capricious. Beca use the plan gives Anthem discretion to deny health benefits if the claimed services are not “m edically necessary,” that decision must be upheld so long as it was not arbitrary and capricious. See Firestone Tire & Rubber Co. v. Bruch , 489 U.S. 101, 114–15 (1989). Under that standard, the administrator’s “decision will be uphe ld unless it is not grounded on any reasonable

6 Dante O. and Tracy O. argued in their opening brief that California Insurance Code § 10110.6 bars the reservation of di scretionary authority in a policy for the purposes of affecting judicial review. Ap lt. Br. at 37. We do not consider this argument because Dante O. and Tracy O. wit hdrew the claim in th eir Reply Brief. Aple. Br. at 28–31; Reply Br . at 13 (“Tracy and Dante w ithdraw their argument that the California Insurance Code prohibition of discretionary authority clause applies to this case” (capitaliz ation removed)).15 basis.” Kimber , 196 F.3d at 1098 (quotations omitted). “This standard is a difficult one for a claimant to overcome.” Nance , 294 F.3d at 1269. 7 Arbitrary and capricious review of an ERISA benefits decision looks to “whether: (1) the decision was the result of a reasoned and principled process, (2) is consistent with any prior in terpretations by the plan admi nistrator, (3) is reasonable in light of any external standa rds, and (4) is consistent with the purposes of the plan.” Flinders v. Workforce Stabilizati on Plan of Phillips Petroleum Co. , 491 F.3d 1180, 1193 (10th Cir. 2007) ( quotations omitted), abrogated on other grounds by Metro Life Ins. Co. v. Glenn , 554 U.S. 105 (2008). A plan administrator’s failure to consistently apply the terms of an ERIS A plan is arbitrary and capricious. Owings v. United of Omaha Life Ins. Co. , 873 F.3d 1206, 1213 (10th Cir. 2017) (holding that shifting interpretations of “disability” was arbitrary and capricious). So is an interpretation inconsistent with the plan’s unambiguous language. Flinders , 491 F.3d at 1193. The district court concluded Anthem’s de nial of S.O.’s residential treatment was reasonable. App. 192 (Order at 15) . “Three physicians—Dr. Cottrell, Dr. Bussel, and Dr. Jack—reviewed S.O.’s medical records and treatment history . . . and determined that residentia l in-patient treatment was not medically necessary.” Id. at 193 (Order at 16). MAXIMUS’ independ ent review of S.O.’s medical records

7 To be clear, only Anthem’s denial of benefits receives Firestone deference. The independent medical determination by MAXIMUS does not receive deference, though it adds support to Anthem’s decision.16 likewise concluded resident ial treatment at New Haven was “not medically necessary.” Aplt. Br. at 23–24. Accordingly, Dante O. and Tracy O. have a difficult task in establishing that Anthem’s d ecision—supported by fo ur doctors—“is not grounded on any reasonable basis.” Kimber , 196 F.3d at 1098 (quot ations omitted). Dante O. and Tracy O. first argu e Anthem “ignored the opinions and observations of S.O.’s treating clinicians who knew her best.” Aplt. Br. at 41. This, they claim, is arbitr ary and capricious, citing Rasenack ex rel. Tribolet v. AIG Life
Ins. Co. , 585 F.3d 1311, 1325 (10th Cir. 2009) and Black & Decker Disability Plan v. Nord , 538 U.S. 822, 823 (2003) . These cases are no cons olation for Dante O. and Tracy O.: they specifically state “ERISA does not require plan administrators to ‘accord special deference to the opinions of treating physicians,’ nor does it place ‘a heightened burden of explan ation on administrators when they reject a treating physician’s opinion.’” Rasenack , 585 F.3d at 1325 (quoting Nord , 538 U.S. at 823). Administrators act within their consider able discretion so long as they do not “arbitrarily refuse to credit . . . th e opinions of a treating physician,” Nord , 538 U.S. at 832. For example, in Rasenack , this court held it was arbitrary and capricious for an administrator to deny a cl aim on the ground there “is no evidence” the claimant suffered hemiplegia when in fact the claimant’s treating physician submitted a letter concluding that the claimant suff ered irreversible hemiplegia. Rasenack , 585 F.3d at
1325. Anthem did not arbitrarily refuse to credit the judgment of S.O.’s treating clinicians; they fully acknowle dged S.O. needed medical ca re. App. 194 (Order at17 17). Dr. Bussel, for instan ce, recommended a psychiat ric intensive structured outpatient program. Id. at 185 (Order at 8). But, as th e district court found, “none of S.O.’s treatment providers offered an opi nion that S.O.’s symp toms and behaviors represented a deterioration” or that her harmful behavior “could not be managed in an outpatient setting.” Id. at 193 (Order at 16). In other words, S.O.’s clinicians did not establish that she met the prerequisites fo r residential treatment. As Dr. Mayes explained: “Due to the nature and chroni city of [S.O.’s] sy mptoms, I do not see a reasonable expectation that the condition a nd illness will be stab ilized or improved” by residential treatment. Id. at 187 (Order at 10). Dante O. and Tracy O. challenge the district court’s fi nding that S.O.’s treatment providers did not opine that S.O. had deteriorated. They quote Maskin’s letter stating that S.O. “w as extremely symptomatic a nd on a daily basis there was concern for her safety,” Aplt. Br. at 21, and Dr. Linda Woodall’s letter stating that S.O.’s “disorder progressed” since 2009 an d she “began to have clear psychotic symptoms” and exhibit “dangerous behavior,” id. at 45. These letters, however, do not establish that Anthem’s decision was ar bitrary and capricious. The district court acknowledged there had been “some dete rioration of S.O.’s symptoms and behaviors,” but no deteriora tion beyond the “usual stat us” of the “consistently troubling” “behaviors and symptoms” S.O. had exhibited since middle school. App. 193 (Order at 16). Although Dante O. a nd Tracy O. claimed S.O.’s symptoms and behaviors were severe enough to require 24-hour, long-term residential care, Dr. Rick Biesinger’s psychological ev aluation of S.O. for her application to New Haven18 claims that S.O. “denied ha ving any suicidal ideation.” Id. at 181 (Order at 4). While S.O. initially told Dr . Biesinger that she cut he rself once a day, she later disclosed the last time she di d so was “two months ago.” Id. Dr. Biesinger’s diagnosis of S.O. (generalized anxiety, moderate depressive disorder, bulimia nervosa) does not suggest a progression in her symptoms so severe that anything short of residential treatment would “risk serious harm.” Id. 8 Anthem’s denial of coverage cannot be said to lack “ any reasonable basis.” Kimber , 196 F.3d at 1098 (quotations omitted). We thus conclude the denial of coverage was not arbitrary and capricious.
III. For these reasons, we affirm th e district court’s judgment.

Entered for the Court

Allison H. Eid Circuit Judge

8 Dante O. and Tracy O. also argue Anthem misapplied its own “medically necessary” criteria. Aplt. Br . at 48–50. But the “risk serious harm” language that Anthem cited in its denial letter, App. 183 (Order at 6), co mes directly from the three-prong criteria identified by the plan to determine whether residential treatment is medically necessary, see id.No. 17-4135, O., et al. v. Anthem Blue Cross Life, et al. BRISCOE , Circuit Judge. I concur in the result.