Opinion ID: 6317310
Heading Depth: 1
Heading Rank: 2

Heading: First DOS

Text: We first consider Wilson’s argument that the district court should have held that United abused its discretion in denying his claims for coverage during the First DOS. In sum, he asserts that United’s decision failed to consider “all relevant medical evidence in support of” coverage. Opening Br. 26. To assess this argument, we begin by reviewing the Plan’s criteria for admission to an inpatient or residential treatment program, turn next to the Booth factors governing a court’s review of a coverage determination, and then recount the district court’s analysis. Lastly, we consider the record in light of Wilson’s challenges to the district court’s determination. We review the district court’s grant of summary judgment de novo, using the same standards as the district court to review the plan administrator’s decisions. Brogan v. Holland, 105 F.3d 158, 161 (4th Cir. 1997). In the ERISA context, the Supreme Court has “significantly curtailed a court’s ability to review a discretionary decision of the 11 administrators of an employee benefits plan,” such that “a reviewing court may reverse the denial of benefits only upon a finding of abuse of discretion.” Id. A. The Plan’s Guidelines for Residential Treatment To assist fiduciaries in making the medical-necessity determination, the Plan permits them to “develop and maintain clinical policies that describe the Generally Accepted Standards of Medical Practice . . .[,] prevailing medical standards and clinical guidelines supporting [medical-necessity] determinations regarding specific services.” J.A. 62. United did so through “Level of Care Guidelines,” which contain criteria relevant to all care and to behavioral health services specifically. J.A. 70. The generally applicable criteria for admission require that the condition for which the patient seeks coverage “cannot be safely, efficiently, and effectively . . . treated in a less intensive level of care,” and that the assessments and treatment of the factors leading to admission “require the intensity of services provided in the proposed level of care.” J.A. 72. In addition to this criteria applicable for all admissions, the particular guidelines for admission to a residential treatment center require: (1) that “[t]he member . . . not [be] in imminent or current risk of harm to self, others, and/or property”; and (2) that the factors that led to admission cannot “be safely, efficiently or effectively assessed and/or treated in a less intensive setting due to acute changes in the member’s signs and symptoms and/or psychosocial and environmental factors.” J.A. 70. Both the initial and continued residential treatment criteria point to the need for such services based on a behavioral or cognitive impairment that interferes with activities of daily life to the extent that the patient’s or others’ welfare is endangered. J.A. 70–72. 12 These standards govern both the utilization review that occurs during the initial benefits determination and during the appeals process. B. Booth’s Legal Standard In Booth, the Court set out a non-exhaustive list of factors to consider when determining whether an ERISA administrator abused its discretion. Those factors assist courts in undertaking their overarching and ultimate review “to determine whether the decision was reasonable,” i.e., “result[ing] from a deliberate, principled reasoning process and . . . supported by substantial evidence.” Griffin v. Hartford Life & Accident Ins. Co., 898 F.3d 371, 381 (4th Cir. 2018) (internal quotation marks omitted). Substantial evidence is evidence that “a reasonable mind might accept as adequate to support a conclusion.” Pearson v. Colvin, 810 F.3d 204, 207 (4th Cir. 2015). Courts should consider the following, non-exhaustive, factors under Booth: the Plan’s language, the materials the administrator consulted in reaching its decision, whether the Plan has been interpreted consistently, “whether the decision was consistent with the procedural and substantive requirements of ERISA,” the existence of “any external standard relevant to the exercise of discretion,” and “the fiduciary’s motives and any conflict of interest it may have.” 201 F.3d at 342–43. C. The District Court’s Analysis The district court weighed the relevant Booth factors and determined that United’s decision to deny coverage for services J.W. received at CALO during the First DOS was the product of a principled and reasoned decisionmaking process. At the outset, the court observed that, under the Plan, United had full discretionary authority to determine 13 eligibility for benefits and there’s no suggestion that it failed to follow the Plan’s procedures in determining the First DOS claims. See id. at 343 (explaining courts should “examin[e] the language of the Plan to determine whether the provision of benefits is prescriptive or discretionary and, if discretionary, whether the plan administrator acted within its discretion”). The district court then examined “the adequacy of the materials considered to make the decision and the degree to which they support it.” Id. at 342. It found that the denial determinations were made after considering adequate materials, which included “J.W.’s treatment history, [his specific] treatment while at CALO, his underlying medical conditions, his family involvement, drugs prescribed to [him], conversations with J.W.’s psychiatrist at CALO, and his complete medical history.” J.A. 2973. And it observed that the denial determinations were later confirmed by an “independent, external reviewer” during Wilson’s external review. Id. The court also found that the decision-making process was reasoned and principled, and supported by substantial evidence. It observed, for example, that United followed Plan procedures and policies throughout the utilization review and first-level internal appeal. Further, the court determined that although “J.W.’s medical records show that he did exhibit isolated incidents that required emergency safety physical interventions during the First DOS, [when] taken in its entirety[,] the administrative record shows that [United’s] decision for a denial of coverage was supported by substantial evidence.” J.A. 2974. Next, the court considered whether United’s decision was consistent with ERISA’s procedural and substantive requirements. In determining that it was, the court observed that 14 United complied with ERISA’s time frames for making each step of the determination, Wilson was timely notified of its findings and next-step rights to appeal the decision, and Wilson did not dispute United’s compliance with ERISA throughout its review of the claims for coverage during the First DOS. Booth also provides that an administrator’s compliance with any external standards are relevant to the reasonableness of its determination, so the district court reviewed New York’s laws governing the denial of health insurance benefits. 4 Specifically, it observed that New York allows for an external review of the denial of benefits, and that United informed Wilson of that right. Wilson did pursue an external appeal, in which the external reviewer independently examined the record and agreed with the determination that J.W.’s treatment was not medically necessary. The court also noted that Wilson did not dispute United’s compliance with New York law. Lastly, the court considered United’s motives and any potential conflicts of interest. Wilson had not asserted any perceived conflicts, but the court nonetheless observed that any potential conflict would be defeated by the external appeal’s independent determination agreeing with United’s determination. Finding that the Booth factors weighed strongly in United’s favor, the district court concluded that it had not abused its discretion in denying coverage for claims submitted for the First DOS. 4 The Plan is subject to New York law. 15 D. Analysis Wilson challenges the district court’s determination, but does not dispute most of its factor-specific analysis under Booth. Instead, he contests the specific conclusion that United’s decision to deny was reasoned and principled, and supported by substantial evidence. He asserts that United “‘cherry picked’ evidence” because “the entirety of the administrative record” shows more than isolated incidents warranting physical intervention and, thus, residential treatment. Opening Br. 41–42. As support, Wilson points to “several” instances in which J.W. engaged in self-harm (scratching, cutting, and hanging over a balcony railing), admitted to suicidal ideation, and got into physical or verbal altercations with staff members or peers. Opening Br. 43. Wilson asserts that only by ignoring this record evidence could United conclude that J.W.’s time at CALO was “essentially unremarkable and uneventful” and thus deny coverage for claims based on the First DOS. Id. Having reviewed the record and the admission guidance, we conclude that United acted within its discretion to deny J.W.’s claims for the First DOS. As a whole, the medical record establishes that J.W. routinely engaged in reciprocal conversations and interacted with both peers and staff. He did not require intensive psychological intervention. Indeed, it appears that J.W. saw a licensed psychiatrist only about one time each month. Against that backdrop, the record does not show that J.W. required constant physical interventions for safety. The noted episodes occurred irregularly and thus do not call into question United’s overarching assessment. Here, the district court fairly characterized the 16 six incidents Wilson identifies as “isolated” considering that they occurred on six days during the First DOS’s five-month span. J.A. 2974. These incidents do not substantially call into question United’s discretion in denying benefits for the First DOS. In a situation with a more closely conflicting medical record to resolve, we observed that it is the ERISA fiduciary’s “duty” “to resolve the conflicts” and “it is not an abuse of discretion for a plan fiduciary to deny benefits where conflicting medical reports were presented.” See Booth, 201 F.3d at 345 (internal quotation marks, citation, and alteration omitted). So long as sufficient evidence supports the decision, and the process by which the determination was made is principled and reasoned, the Court has “no basis” to second-guess an administrator’s denial of benefits. Id. at 346. Before issuing a final determination to deny coverage, three levels of review occurred—the initial utilization review, the first-level internal appeal, and an external review. The three independent reviewers separately arrived at the same conclusion: the 24hour residential setting of services provided at CALO were no longer needed by the beginning of—and throughout—the First DOS. E.g., J.A. 2867–68 (denying coverage at the utilization review stage after determining that J.W. “did not need the 24 hour monitoring provided in a residential setting, and care could have been provided at a lower level of care” such as an “intensive outpatient setting with individual psychotherapy, family therapy and medication management”); J.A. 2889 (upholding the initial determination on appeal because during the First DOS J.W.’s “behaviors had improved” and “[h]e appeared to be able to continue his care at a day program,” which was “available in [the Wilsons’] home area,” and thus did not meet the criteria for residential treatment); J.A. 2856 17 (agreeing, at the external appeal stage, that residential treatment “was not medically necessary” because “[n]othing in the documentation reviewed indicates that this patient required or could benefit from 24-hour daily confinement, observation, and treatment” and that a “more appropriate treatment plan would have included intensive outpatient treatment with a very strong family therapy component while the patient lived in his community with his family”). That determination is consistent with the criteria United established pursuant to the Plan, which set out that coverage can be denied for not being medically necessary when care could have occurred at a less intensive setting.