Court Opinion

ID: 9392075
Source: CourtListenerOpinion
Date Created: 2023-05-04 00:00:31.848609+00
Date Added: 2024-06-11T17:18:44.367671
License: Public Domain

Case: 22-30573         Document: 00516736970             Page: 1      Date Filed: 05/03/2023

              United States Court of Appeals
                   for the Fifth Circuit
                                                                                      United States Court of Appeals
                                                                                               Fifth Circuit

                                      ____________                                           FILED
                                                                                          May 3, 2023
                                        No. 22-30573                                    Lyle W. Cayce
                                      ____________                                           Clerk

   Robert L. Salim,

                                                                       Plaintiff—Appellee,

                                             versus

   Louisiana Health Service & Indemnity Company, doing
   business as Blue Cross and Blue Shield of Louisiana,

                                               Defendant—Appellant.
                      ______________________________

                      Appeal from the United States District Court
                         for the Western District of Louisiana
                                USDC No. 1:19-CV-442
                      ______________________________

   Before Higginbotham, Southwick, and Willett, Circuit Judges.
   Per Curiam: *
          Robert Salim purchased health insurance from the Louisiana Health
   Service & Indemnity Company (“Blue Cross”). Salim later sought coverage
   for proton beam therapy to treat his throat cancer. Citing an internal
   guideline, Blue Cross denied coverage, deeming proton therapy not
   medically necessary. Salim sued, arguing that the guideline relied on a third-

          _____________________
          *
              This opinion is not designated for publication. See 5th Cir. R. 47.5.
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                                    No. 22-30573

   party source that had since been updated to specifically approve proton
   therapy for exactly his condition. The district court held that the denial was
   an abuse of discretion, and it ordered Blue Cross to provide coverage. We
   AFFIRM.

                                         I
          Salim is a business owner who bought a health-insurance plan from
   Blue Cross to cover himself and his employees (the “Plan”). While the Plan
   was in effect, Salim was diagnosed with throat cancer. His medical provider
   requested preauthorization for “proton therapy” from AIM Specialty
   Health, a company that helps Blue Cross administer the Plan. AIM denied
   the treatment as “not medically necessary.” AIM reasoned that Salim had
   no history of cancer, and that proton therapy is used only “when the same
   area has been radiated before.” AIM also denied Salim’s appeal. AIM’s
   denials cited only one source: the “clinical appropriateness guideline titled
   Radiation Oncology: Proton Beam Therapy” (the “Guideline”).
          Salim appealed to Blue Cross, which denied the appeal. Relying solely
   on the Guideline, Blue Cross explained that “proton beam radiation therapy
   is not considered medically necessary in adult patients with head and neck
   cancer.” Salim then initiated a second-level appeal with Blue Cross by
   requesting that an independent medical organization review the denial. As
   part of that appeal, Dr. Clifton Fuller, who is Salim’s physician, described
   three flaws in the Guideline that AIM and Blue Cross had relied on.
          Dr. Fuller first argued that the Guideline relied on an outdated and
   superseded policy issued by the American Society for Radiation Oncology
   (the “ASTRO Policy”). According to Dr. Fuller, the ASTRO Policy
   “ha[d] been updated . . . to specifically include proton beam therapy as both
   appropriate and medically necessary for exactly Mr. Salim’s diagnosis,
   advanced head and neck cancer.” Second, Dr. Fuller argued that the

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   Guideline “glaringly omitted” reference to a separate source, the National
   Comprehensive Cancer Network Head and Neck Guidelines (the “NCCN
   Policy”). Id. Dr. Fuller viewed that omission as questionable because Blue
   Cross did rely on NCCN recommendations for “other disease sites.” Third,
   Dr. Fuller pointed out that the Guideline cited only three articles related to
   head and neck cancer, and that all three “specifically endorse the use of
   proton therapy” for head and neck cancer.
          After describing the AIM Guideline’s three flaws, Dr. Fuller went on
   to explain why he viewed proton therapy as medically necessary for Salim’s
   condition. He cited over a dozen evidence-based publications as support for
   his conclusion that proton therapy was medically necessary. He also
   explained that the ASTRO Policy and the NCCN Policy each “consider
   proton beam therapy the standard of care.”
          Blue Cross referred Salim’s second-level appeal to an independent
   reviewer, the Medical Review Institute of America (the “Institute”). The
   Institute denied the appeal, giving two reasons. First, citing several articles,
   the Institute explained that “most investigators recommend additional study
   . . . before adopting [proton therapy] as a standard treatment option for
   patients with head and neck cancer.” Second, the Institute concluded that
   the ASTRO Policy and the NCCN Policy support proton therapy for head
   and neck cancer only when the patient has “a lesion with significant
   involvement of structures at the skull base.” According to the Institute,
   Salim “d[id] not have significant macroscopic disease involvement in the
   region of the skull base,” and therefore the ASTRO and NCCN Policies
   did not support proton therapy as medically necessary to treat his cancer.
          The Institute’s decision operated as a final denial of coverage. Despite
   that denial of coverage, Salim chose to undergo proton therapy.

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          Salim sued Blue Cross in Louisiana state court, but Blue Cross
   removed to federal court. There, the parties stipulated that ERISA (the
   Employee Retirement Income Security Act, 29 U.S.C. §§ 1001–1462)
   governs the Plan and preempts all state-law causes of action. They also
   stipulated that Blue Cross has full discretion “to determine eligibility for
   benefits” and “construe the terms of the Plan.” Salim argued that Blue
   Cross’s denial was an “arbitrary and capricious” abuse of discretion because
   it relied on “outdated literature,” and he asked the district court to
   “reverse[]” the denial of coverage. The district court assigned the case to a
   magistrate judge.
          The magistrate judge agreed with Salim. Because the Plan gives Blue
   Cross full discretionary authority to make determinations regarding benefits,
   the judge reviewed Blue Cross’s denial of coverage for an abuse of discretion.
   The parties agreed that the Plan covers only “medically necessary”
   treatments, and they agreed on that term’s plain meaning. Accordingly, the
   magistrate judge framed the question as whether “[Blue Cross] abused its
   discretion in finding that [proton therapy] is not the accepted standard of care
   for [Salim’s] head and neck cancer—a fact related to coverage.” After
   reviewing the overlapping denial explanations from AIM, Blue Cross, and
   the Institute, the magistrate judge found that “substantial evidence does not
   support [Blue Cross]’s finding that [proton therapy] was not medically
   necessary for treatment of Salim’s cancer.” Accordingly, the magistrate
   judge concluded that Blue Cross “abused its discretion in denying
   coverage.”
          The district court adopted the magistrate judge’s report and
   recommendation, and it entered summary judgment for Salim “on the issue
   of coverage” for proton therapy. The court also ordered Blue Cross “to pay
   Salim’s medical bills stemming from his receipt of the subject [proton
   therapy] treatments.” Blue Cross timely appealed.

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                                          II
          We review “summary judgment de novo, applying the same legal
   standards that controlled the district court’s decision.” White v. Life Ins. Co.
   of N. Am., 892 F.3d 762, 767 (5th Cir. 2018) (citing Robinson v. Aetna Life Ins.
   Co., 443 F.3d 389, 392 (5th Cir. 2006)). In other words, we “review the plan
   administrator’s decision from the same perspective as the district court.”
   Foster v. Principal Life Ins. Co., 920 F.3d 298, 304 (5th Cir. 2019) (quoting
   Meditrust Fin. Servs. Corp. v. Sterling Chems., Inc., 168 F.3d 211, 214 (5th Cir.
   1999)).
          Blue Cross argues that the district court should have treated proton
   therapy’s medical necessity as a legal question (rather than a factual
   question). In the alternative, Blue Cross argues that substantial evidence
   supports its decision to deny coverage for proton therapy. We disagree on
   both fronts.
                                          A
          Because the Plan “lawfully delegates discretionary authority” to Blue
   Cross, judicial review “is limited to assessing whether the administrator [that
   is, Blue Cross] abused that discretion.” Ariana M. v. Humana Health Plan of
   Texas, Inc., 884 F.3d 246, 247 (5th Cir. 2018) (en banc) (citing Firestone Tire
   & Rubber Co. v. Bruch, 489 U.S. 101, 115, (1989)). A plan administrator can
   abuse its discretion by denying claims “based on legal or factual grounds.”
   Id. at 248 (emphasis added). Legal grounds include “interpretation” of a
   plan’s terms, whereas factual grounds include “application” of a plan’s
   terms. Rittinger v. Healthy All. Life Ins. Co., 914 F.3d 952, 956 (5th Cir. 2019)
   (per curiam) (emphasis omitted).
          For legal disputes—that is, disputes about a plan’s meaning—the
   abuse-of-discretion analysis has “two steps.” Encompass Off. Sols., Inc. v. La.
   Health Serv. & Indem. Co., 919 F.3d 266, 282 (5th Cir. 2019). The first step

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   asks whether the administrator’s reading is “legally correct.” Id. “If so, the
   inquiry ends, and there was no abuse of discretion.” Id. But if not, then we
   proceed to the second step, which uses several factors to determine whether
   the administrator’s legally erroneous interpretation of the plan’s terms still
   falls within the administrator’s discretion. See id.
          For factual disputes—that is, disputes about a plan’s application—the
   abuse-of-discretion analysis asks whether the administrator relied “on
   evidence, even if disputable, that clearly supports the basis for its denial.”
   Nichols v. Reliance Standard Life Ins. Co., 924 F.3d 802, 808 (5th Cir. 2019)
   (quoting Holland v. Int’l Paper Co. Ret. Plan, 576 F.3d 240, 246 (5th Cir.
   2009)). “If the [administrator]’s decision is supported by substantial
   evidence and is not arbitrary and capricious, it must prevail.” Id. (emphasis
   added) (quoting Killen v. Reliance Stand. Life Ins. Co., 776 F.3d 303, 307 (5th
   Cir. 2015)). “Substantial evidence is more than a scintilla, less than a
   preponderance, and is such relevant evidence as a reasonable mind might
   accept as adequate to support a conclusion.” Id. (quoting Ellis v. Liberty Life
   Assur. Co. of Bos., 394 F.3d 262, 273 (5th Cir. 2004)). “A decision is arbitrary
   only if made without a rational connection between the known facts and the
   decision or between the found facts and the evidence.” Id. (quoting Foster v.
   Principal Life Ins. Co., 920 F.3d 298, 304 (5th Cir. 2019)). In sum, “we must
   uphold the determination if our review ‘assures that the administrator’s
   decision falls somewhere on a continuum of reasonableness—even if on the
   low end.’” Id. (alterations adopted) (quoting Holland, 576 F.3d at 247)).
          The district court correctly concluded that this case involves a
   “factual dispute” rather than an “interpretive dispute.” See Rittinger, 914
   F.3d at 956. Blue Cross and Salim agree that the Plan covers only “medically
   necessary” treatments, and they agree on that term’s definition. Because the
   parties agree about what the Plan means, their dispute involves only the
   “application of the [P]lan terms.” Id. Thus, the question is whether proton

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   therapy was medically necessary to treat Salim’s cancer. “[T]he decision to
   deny benefits based on lack of medical necessity involves a review of the
   facts.” Meditrust Fin. Servs. Corp., 168 F.3d at 214; see Katherine P. v. Humana
   Health Plan, Inc., 959 F.3d 206, 208 (5th Cir. 2020). 1
           Blue Cross’s contrary arguments are unavailing. For instance, Blue
   Cross argues that a court should look for an abuse of discretion “[o]nly if the
   court finds the administrator did not give the plan the legally correct
   interpretation.” Similarly, Blue Cross argues that the “interpretation of the
   Plan is necessarily in dispute” because “the only place ‘medically necessary’
   is defined is the Plan.” This line of argument errs by trying to replace the
   “substantial evidence” factual analysis with the two-step legal analysis for
   interpretive errors. See Rittinger, 914 F.3d at 956 (distinguishing between
   “(1) an interpretive dispute and (2) a factual dispute” (quotations omitted));
   Meditrust Fin. Servs. Corp., 168 F.3d at 214 (rejecting the standard-of-review
   argument that Blue Cross advances here).
           Blue Cross also argues that the district court erred by drawing “a
   distinction between a claim for coverage for medical services . . . and a claim
   for benefits.” We disagree. The district court used the words “eligibility for
   benefits” when referring to the Plan’s meaning (a question of law), but it
   used the word “coverage” when referring to the Plan’s application (a
   question of fact). In context, the district court was distinguishing factual
   questions from legal questions; it was not distinguishing coverage from
   benefits. The district court was therefore correct that “the test for a legally
           _____________________
           1
             Medical necessity is not always a question of fact. For example, a question of law
   arises—and the two-step abuse-of-discretion framework applies—when the parties’
   dispute requires a court to “interpret[] the term ‘medically necessary’ as expressly defined
   in the insurance contract.” Dowden v. Blue Cross & Blue Shield of Tex., Inc., 126 F.3d 641,
   643 (5th Cir. 1997) (per curiam). Here, however, the question is one of application—not
   interpretation.

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   correct construction of the Plan is not applicable in this case.” Instead, the
   “substantial evidence” standard governs. See Nichols, 924 F.3d at 808.
                                          B
          We also agree with the district court that “substantial evidence does
   not support” Blue Cross’s decision. In this ERISA case, substantial
   evidence “is such relevant evidence as a reasonable mind might accept as
   adequate to support a conclusion.” Rittinger, 914 F.3d at 957 (citation
   omitted). Blue Cross is “not legally obligated to weigh any specific
   physician’s opinion more than another’s.” Holland, 576 F.3d at 250. Rather,
   if there is “more than a scintilla” of evidence supporting denial, then Blue
   Cross prevails—as long as its decision “is not arbitrary and capricious.”
   Nichols, 924 F.3d 808 (citations omitted); cf Michael J. P. v. Blue Cross & Blue
   Shield of Tex., 2021 WL 4314316, at *9 (5th Cir. 2021) (Oldham, J.,
   concurring) (“ERISA’s ‘substantial evidence’ is radically different from
   ‘substantial evidence’ elsewhere in law.”). That is because a court is “not
   supposed to weigh and balance the evidence.” Rittinger, 914 F.3d at 960.
   Still, even under this highly deferential scheme, “a plan administrator ‘may
   not arbitrarily refuse to credit a claimant’s reliable evidence.’” Schexnayder
   v. Hartford Life & Acc. Ins. Co., 600 F.3d 465, 469 (5th Cir. 2010) (quoting
   Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003)).
          Under the Plan, a treatment is “medically necessary” if it is (A) “in
   accordance with nationally accepted standards of medical practice,” (B)
   “clinically appropriate,” and (C) “not primarily for the personal comfort or
   convenience of the patient, or Provider, and not more costly than alternative
   services . . . that are as likely to produce equivalent therapeutic or diagnostic
   results.” Blue Cross argues that the record contains substantial evidence
   showing that proton therapy is not “in accordance with nationally accepted
   standards” (element (A)). Blue Cross also argues that there is “no evidence”
   regarding whether proton therapy was “clinically appropriate,” primarily for

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   “personal comfort,” or “not more costly than alternative services”
   (elements (B) and (C)). We disagree.
          Start with AIM’s denials and with Blue Cross’s first-level appeal
   denial. Each cited only one source for denying coverage for proton therapy:
   the Guideline. The Guideline, in turn, relied on the ASTRO Policy as a
   nationally accepted standard. Yet as Dr. Fuller pointed out, the ASTRO
   Policy “has been updated . . . to specifically include proton beam therapy as
   both appropriate and medically necessary for exactly Mr. Salim’s diagnosis,
   advanced head and neck cancer.” Indeed, the ASTRO Policy designates
   proton therapy as “medically necessary” both for “[t]umors that approach
   or are located at the base of the skull” and for “[a]dvanced . . . head and neck
   cancers.”
          The updated ASTRO Policy is not competing evidence that requires a
   court to weigh one policy against another. Rather, the updated Policy is
   superseding evidence showing that ASTRO—a source which AIM and Blue
   Cross treated as reliable—in fact classifies proton therapy as medically
   necessary for Salim’s condition. A plan administrator “may not arbitrarily
   refuse to credit a claimant’s reliable evidence.” Schexnayder, 600 F.3d at 469;
   (quoting Black & Decker, 538 U.S. at 834). Perhaps Blue Cross has discretion
   to ignore ASTRO altogether. But it does not have discretion to deny Salim’s
   claim by attributing to ASTRO a view that ASTRO does not hold.
          The Institute’s review does not cure Blue Cross’s decision. Consider
   the Institute’s statement that “most investigators recommend additional
   study . . . before adopting [proton therapy] as a standard treatment option for
   patients with head and neck cancer.” This generic claim about unnamed
   investigators does nothing to address the problem that Dr. Fuller highlighted,
   which was that the investigator that Blue Cross trusted—ASTRO—in fact
   viewed proton therapy as medically necessary for Salim’s diagnosis. Nor did

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   Dr. Fuller recommend proton therapy as a “standard” treatment. Just the
   opposite: “I am not advocating for the routine treatment of head and neck
   cancer; Mr. Salim has massive oral disease.” Given the ASTRO Policy that
   Blue Cross relied on, the Institute’s generic claim is not “such relevant
   evidence as a reasonable mind might accept as adequate to support” the
   denial. Rittinger, 914 F.3d at 957 (citation omitted).
          Nor do we see substantial evidence in the Institute’s conclusion that
   the updated ASTRO Policy and the NCCN Policy support proton therapy
   for head and neck cancer only when the patient has “a lesion with significant
   involvement of structures at the skull base.” Relevant excerpts from both
   Policies are in the record. The ASTRO Policy designates proton therapy as
   “medically necessary” for “tumors . . . at the base of the skull” or for
   “[a]dvanced head and neck cancers.” “[A]dvanced head and neck cancer”
   was Salim’s exact diagnosis. The Institute did not address this aspect of the
   ASTRO Policy. The NCCN Policy says that proton therapy is “especially
   important” for tumors that “invade . . . the skull base.” According to the
   Institute, Salim “d[id] not have significant macroscopic disease involvement
   in the region of the skull base,” and therefore the NCCN Policy did not
   apply. But the NCCN Policy requires only that the disease “invade” the
   skull base, not that the invasion be “significant.” Salim’s cancer involved
   “skull base invasion.” Again, then, the Institute did not address the full range
   of diagnoses that the NCCN Policy refers to.
          Finally, Blue Cross argues that “there is no evidence in the [record]
   that [Salim] met his burden as to parts B and C” of the Plan’s definition of
   “medically necessary.” Blue Cross also complains that “the District Court
   d[id] not discuss the B and C provisions.” That silence is not surprising given
   that Blue Cross did not make this argument in the brief that it submitted to
   the magistrate. But Blue Cross did present this argument in its objection to

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   the magistrate judge’s report and recommendation, albeit in only a few
   conclusory sentences. Assuming this argument is preserved, it lacks merit.
          Dr. Fuller explained at length that proton therapy was appropriate “in
   this scenario” (element (B)), and that proton therapy was also “less cost[ly]”
   than and otherwise “[s]uperior” to other treatment options (element (C)).
   That explanation satisfied Salim’s “initial burden of demonstrating
   entitlement to benefits under an ERISA plan.” Perdue v. Burger King Corp.,
   7 F.3d 1251, 1254 n.9 (5th Cir. 1993). Blue Cross had a chance to rebut Dr.
   Fuller’s view with substantial evidence, but it focused instead on element
   (A). On appeal, Blue Cross has identified no evidence in the record that
   favors its view of elements (B) and (C), nor do we discern any such evidence.
   As a result, Blue Cross’s final argument fails.

                                         III
          The district court used the correct standard of review, and it correctly
   held that Blue Cross abused its discretion by denying coverage even when
   substantial evidence did not support that decision. We AFFIRM.

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