Court Opinion

ID: 56799
Source: CourtListenerOpinion
Date Created: 2010-04-26 01:57:35+00
Date Added: 2024-06-11T17:19:36.718867
License: Public Domain

IN THE UNITED STATES COURT OF APPEALS
                    FOR THE FIFTH CIRCUIT United States Court of Appeals
                                                   Fifth Circuit

                                                                            FILED
                                                                         December 7, 2007

                                       No. 07-20016                   Charles R. Fulbruge III
                                                                              Clerk

QUALITY INFUSION CARE INC

                                                  Plaintiff - Appellant
v.

AETNA LIFE INSURANCE COMPANY INC

                                                  Defendant - Appellee

                   Appeal from the United States District Court
                        for the Southern District of Texas
                             USDC No. 4:05-CV-2929

Before Reavley, Smith, and Garza, Circuit Judges.
PER CURIAM:*
       Plaintiff-Appellant Quality Infusion Care, Inc. brought suit under the
Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001 et seq.
against Aetna Life Ins. Co. Quality contends that Aetna wrongfully denied
claims for benefits related to services performed by Quality for R.A., who was
indisputably covered under the employee welfare benefits plan funded by a

       *
         Pursuant to 5TH CIR. R. 47.5, the court has determined that this opinion should not
be published and is not precedent except under the limited circumstances set forth in 5TH CIR.
R. 47.5.4.
                                        No. 07-20016

group insurance policy issued by Aetna.1 Quality appeals the district court’s
grant of summary judgment to Aetna. For the following reasons, we affirm the
district court’s judgment.
       1.     We review the district court’s grant of summary judgment de novo.
              Texas Indus., Inc. v. Factory Mut. Ins. Co., 486 F.3d 844, 846 (5th
              Cir. 2007). Summary judgment is appropriate if the record shows
              “that there is no genuine issue as to any material fact and that the
              moving party is entitled to a judgment as a matter of law.” FED. R.
              CIV. P. 56(c).
       2.     Quality alleges that summary judgment to Aetna is improper
              because Aetna ignored medical information submitted by Quality
              and because Aetna’s reviewing nurses and physicians were not
              qualified to determine whether treatment Quality provided to R.A.
              was medically necessary.
                      Quality’s arguments fail. Aetna did not ignore the medical
              information submitted by Quality. It merely relied on its pre-
              published        clinical    policy     specifying       when      intravenous
              immunoglobulin (“IVIG”) treatments are considered medically
              necessary and determined that the criteria was not met. We have
              held that an insurer’s reliance on a pre-published plan to determine
              what is “medically necessary” can be reasonable under ERISA.
              Dowden v. Blue Cross & Blue Shield of Texas, Inc., 126 F.3d 641,
              644 (5th Cir. 1997). And, contrary to Quality’s contention, Aetna
              accurately followed its pre-published policy, Aetna Clinical Policy
              Bulletin 206 (“CPB 206”), when denying Quality’s request that it

       1
          R.A. assigned his rights, benefits, and claims under the plan to Quality, including the
right to receive payments for benefits. Aetna does not challenge Quality’s status as a valid
assignee.

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                            No. 07-20016

        cover the IVIG services provided to R.A. CPB 206 plainly precludes
        coverage for R.A.’s treatments, so we find no merit to Quality’s
        contention that Aetna’s reviewers were unqualified to make this
        determination. Because Quality does not argue that CPB 206’s
        requirements are improper, there is no basis to hold that Aetna
        wrongfully denied coverage for Quality’s services.
AFFIRMED.

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