Opinion ID: 6317310
Heading Depth: 3
Heading Rank: 1

Heading: Claims for Coverage During the First DOS

Text: United denied Wilson’s claims for the First DOS based on its finding that J.W.’s residential treatment was not medically necessary. A letter from United explained that coverage was unavailable because J.W. “was admitted for inpatient treatment of his mood problems” that “did not need the 24-hour monitoring provided in a residential setting [given that] care could have been provided at a lower level of care such as partial hospital or intensive outpatient services.” J.A. 2873. Specifically, a board-certified psychiatrist made the initial benefits determination based on CALO’s records and other clinical records concerning the services provided to J.W. She determined that J.W. made progress in the months preceding the First DOS such that he did not satisfy the Plan’s criteria for 5 residential treatment. She pointed in particular to the lack of evidence that J.W. had a severe lack of behavioral control, required frequent medication changes, or needed 24-hour monitoring. On Wilson’s behalf, CALO appealed the denial of coverage for the First DOS. Consistent with the Plan’s procedures, United assigned the appeal to a different psychiatrist who was not involved in the initial denial. After reviewing “all aspects of clinical care involved in [J.W.’s] treatment” and discussing J.W.’s condition with his treating psychiatrist, the appeal psychiatrist upheld the initial determination to deny benefits. J.A. 2889. In sum, he concluded that J.W.’s “behaviors had improved” by December 1, 2015, such that any disruptive episodes could have been safely treated in an outpatient setting. Id. CALO next sought an external appeal, which similarly upheld the denial as not medically necessary.