Opinion ID: 4564067
Heading Depth: 3
Heading Rank: 3

Heading: The member has a co-occurring medical

Text: disorder or substance use disorder which complicates treatment of the presenting mental health condition to the extent that treatment in a Residential Treatment Center is necessary. No party argues that Doe met the third criterion; instead, Doe maintains that she qualified for residential treatment under the first two criteria. The district court -- like Harvard Pilgrim -- found that Doe did not meet either of the first two criteria as of February 13, 2013.1 1 For continued care after initial approval, the Guidelines require -- among other things -- that [t]he criteria [listed above] for the current level of care continue to be met and [t]he member's current symptoms and/or history provide evidence that relapse or a significant deterioration in functioning would be imminent if the member was transitioned to a lower level of care. - 7 - Doe's overarching argument on appeal is that the expert reports that formed the basis for Harvard Pilgrim's denials of coverage improperly used an incorrect standard of care, essentially requiring that she need 24-hour nursing care, even though the Guidelines state explicitly that residential treatment should be available to members who do not require 24-hour nursing care and monitoring offered in an acute inpatient setting but who do require 24-hour structure. Specifically, the OPP reviewer justified his or her decision based on finding no evidence that the patient required 24 hour supervision or nursing care, and Dr. Rubenstein's report similarly repeatedly references 24 hour care as the relevant benchmark without mentioning the Guideline's language of 24-hour structure. (The only other expert in the record to conclude that the first admission was not necessary after February 13, 2013, Dr. Bennett, did not reference the Guideline language at all.) We disagree with Doe: It was not clear error for the district court to rely on these reports despite their references to 24-hour care. To begin, it was hardly error for the experts to cite the lack of any need for round-the-clock care in the first place. The experts would have erred only if they opined that a Because we uphold the district court's decision that the standard for the current level of care was not met as of February 13, it follows that the criteria for continued care were not met at that point. - 8 - need to receive such care was necessary to qualify for the coverage. The district court did not commit clear error in opting not to read the expert reports in that manner. The OPP report in particular based its conclusion on a finding that Doe did not need 24 hour supervision or nursing care (emphasis added). More generally, when read in context, the references to 24-hour care can be understood as referring to the availability of such care as provided by Riggs. Thus, even Doe's own expert, Dr. Harris, referred to Doe's repeated accessing of 24-hour nursing care during the night, presumably intending to say only that Doe needed nursing care to be available around the clock, not that she needed care to be actively provided for 24 hours each day. The district court's opinion can then be read to explain that Doe did not require 24-hour structure either. For example, the district court considered the length and frequency of Doe's trips away from Riggs (totaling nearly twenty days away) and the ways in which she utilized the services that were available to her there and concluded that all Doe needed was a system in which she could access nursing care each day to arrange a plan for safely managing her symptoms at night if necessary. Although Doe argues that the district court should not have assumed Doe would have that ability at a lower level of care, she has not developed the record on why a partial hospitalization program would have been insufficient. - 9 - Doe's further arguments are similarly unavailing given the clear error standard of review. Although Doe argues that the district court should have drawn different inferences from facts including her difficulty with interpersonal relationships inside and outside Riggs, her difficult but perhaps supportive relationship with her family, her ability to ask for and access the services she needed at Riggs, the casual tenor of her interactions with nursing staff, and her ability to spend time away from Riggs for recreation and other personal reasons during her admission, we do not believe the district court clearly erred in making the inferences that it did, many of which were supported by the Bennett and Rubenstein reports. Nor do we fault the district court for relying on evidence that Doe's condition had stabilized on medication leading up to the February 13 date. While Doe's condition obviously deteriorated at some point after that, it was not clear error for the district court to conclude that, at least at that point, her continued stay at Riggs was not medically necessary. Finally, Doe complains that the district court accepted the opinions of Harvard Pilgrim’s experts without weighing their conclusions against the weight of the record. We disagree. The district court clearly reviewed the record as a whole, drawing inferences from both the facts and the expert opinions. We find - 10 - no clear error in the fact that the district court implicitly agreed more with Harvard Pilgrim's experts than with Doe's.