A Jessica U. v. Health Care Service Corp., a Montana district court found that an ERISA plan administrator unduly denied benefits for residential mental health treatment based solely on so-called “Milliman Care Guides” that were not included in the plan documents. .
The Milliman Care Guidelines (“MCGs”) are a set of good practices, guidelines, and diagnostic criteria for the healthcare industry published by MCG Health for providers and health plans. Although health professionals make extensive use of GCMs, the case of Jessica U. illustrates that plan administrators should be careful when relying on guidelines or other materials outside the plan as reasons for deny the health benefits.
In Jessica U., the plaintiff was a beneficiary teenager dependent on a group health plan provided by her father’s employer with a history of gastric problems and panic attacks that prevented her from attending school. He spent three months at a Montana residential treatment center (“RTC”) for an eating disorder in mid-2015. After admission, the center’s medical staff found that the plaintiff met the diagnostic criteria for anorexia. nervous and generalized anxiety disorder and that a major depressive disorder could not be ruled out.
Plaintiff sought coverage for RTC treatment under an ERISA plan (the “plan”) issued by defendant Health Care Service Corporation, which operates in Montana as the Blue Cross Blue Shield of Montana (“BCBS”). The plan covered treatment in RTCs, as long as the treatment was considered “medically necessary,” as defined in the plan. In addition, in making a determination of the “medical need,” the plan allowed BCBS to consider “standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, recommendations from the Physician Specialty Society and the opinion of physicians practicing in relevant clinical areas and any other relevant factors “. However, the Plan did not specifically address the MCG.
BCBS approved coverage for the plaintiff’s first three months of residential treatment, after which she returned home. Shortly afterwards, the plaintiff’s symptoms resurfaced and she sought coverage for further treatment at the RTC. BCBS denied additional treatment coverage, relying solely on the MCG to conclude that the plaintiff’s RTC treatment was not “medically necessary.” Specifically, BCBS found that the plaintiff was not in imminent danger to herself or to others, had no self-care problems, had no severe disability requiring acute residential intervention, did not have comorbid substance abuse disorders, and it did not require a structured environment. with continuous attention 24 hours a day: standards that are included in the MCG but are not explicitly explained in the plan documents.
The plaintiff exhausted administrative appeals and then filed a federal lawsuit challenging the denial.
In granting the plaintiff’s motion for summary judgment, the district court held that a plan administrator could properly use the MCG as a complementary tool to analyze a mental health benefit claim. BCBS, however, erred in relying solely on the guidelines for denying the plaintiff’s claim because they included acute care factors that had limited application to a case involving non-acute income.
As a result, the court held that the BCBS review lost track because “many relevant factors are detailed in [plaintiff’s] BCBS did not consider treatment, progress, and struggles. On the contrary, there were factors applied to [plaintiff’s] application for benefits that have nothing to do with your mental health problems. “
Rejecting BCBS’s approach, the court applied a de novo review of the administrative record and held that the plaintiff had satisfied the plan’s definition of medical necessity. The case of Jessica U. is a reminder for plan administrators to act judiciously when they rely on third-party documents and ensure that those documents respond directly to the conditions claimed.