Opinion ID: 683609
Heading Depth: 2
Heading Rank: 3

Heading: Medically Necessary

Text: 42 The district court determined that the care Nightingale rendered to Lungarella from July 20 until September 5, 1987, was medically necessary under the Plan definition. Blue Cross contends that the district court erred in its determination. We disagree. 43 The record demonstrates that the Nightingale nurses provided a variety of services during the last seven weeks of Lungarella's life that were essential to prolonging his life and maintaining its best possible quality as he suffered through the final days of his illness. The nurses provided care relating to Lungarella's outbreaks of herpes lesions on his coccyx. This care was especially important with Lungarella because AIDS patients experience incontinence of urine and feces and if not cleaned and treated can increase the risk of infection. The proximity of the lesions to the sources of incontinence dictated rapid response. RIII-74-123-125, 130-134, 139-140. The nurses also monitored numerous indicators of Lungarella's health and filled out complex charts daily. The nurses were also prepared for emergencies. Lungarella had many sores on his mouth and tongue which made it difficult to eat and breathe. The nurses were present to deal with crises as they might arise; i.e., to clear his breathing tubes if they became clogged. The nurses also provided trained support for the numerous psychological problems associated with AIDS. As such, the district court correctly determined that the care Lungarella received in the last seven weeks of his life was medically necessary. 44 Since Nightingale offered a reasonable interpretation of the medically necessary provision under which the care would be covered, according to Lee v. Blue Cross/Blue Shield of Alabama, 10 F.3d 1547 (11th Cir.1994), Blue Cross must offer a reasonable interpretation under which the care would not be covered and prove its denial of the claim was not tainted by self-interest. Blue Cross has done neither. Holloway analyzed medically necessary under separate guidelines contained in another Blue Cross document that is not even mentioned in the Plan. RII-55-15, 16. These separate guidelines are contained in the Pre-certification of Private Duty Nursing Policy. RII-63-Tab 8. This Pre-certification Policy enunciates a different definition of medically necessary than the one contained in the Plan. Holloway imported an additional requirement from the Pre-certification definition of medically necessary and injected it into her analysis. A claims administrator's decision is arbitrary and capricious where new requirements for coverage are added to those enumerated in the plan. See Helms v. Monsanto Company, Inc., 728 F.2d 1416, 1420 (11th Cir.1984) (holding a claims administrator's denial of disability benefits was arbitrary and capricious where he read a requirement of no conscious life into a plan definition of total disability). Holloway admittedly never actually analyzed the elements of medically necessary that are listed in the Plan. RIII-74-159, 160. Accordingly, Holloway's decision was arbitrary and capricious, and the district court correctly determined that Holloway's decision was incorrect.