Kimberley D. v. United Healthcare Ins. Co. ( 2018 )


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  •                            NOT FOR PUBLICATION
    UNITED STATES COURT OF APPEALS
    FILED
    FOR THE NINTH CIRCUIT
    MAR 21 2018
    MOLLY C. DWYER, CLERK
    U.S. COURT OF APPEALS
    KIMBERLEY D.,                                    No.   16-56175
    Plaintiff-Appellant,               D.C. No.
    3:15-cv-01012-JM-JLB
    v.
    UNITED HEALTHCARE INSURANCE                      MEMORANDUM*
    COMPANY,
    Defendant-Appellee.
    Appeal from the United States District Court
    for the Southern District of California
    Jeffrey T. Miller, District Judge, Presiding
    Argued and Submitted February 6, 2018
    Pasadena, California
    Before: REINHARDT, W. FLETCHER, and OWENS, Circuit Judges.
    Kimberley D. (“Appellant”) appeals the district court’s judgment in favor of
    United Healthcare Insurance Company (“United Healthcare”), affirming denial of
    benefits. Appellant contends that United Healthcare breached its LifeLock, Inc.
    *
    This disposition is not appropriate for publication and is not precedent
    except as provided by Ninth Circuit Rule 36-3.
    Welfare Benefit Plan (“Plan”), as administered through United Behavioral Health
    (“UBH”), when it determined that her residential treatment was not “medically
    necessary” and thus not covered by the Plan. Appellant also contends that the
    district court was overly deferential to United Healthcare’s decision and did not
    give enough credit to contrary information in the record. We have jurisdiction
    under 28 U.S.C. § 1291, and we affirm.
    We review de novo the question whether the district court correctly applied
    de novo review when considering Appellant’s claim. See Abatie v. Alta Health &
    Life Ins. Co., 
    458 F.3d 955
    , 962 (9th Cir. 2006) (en banc); Lang v. Long-Term
    Disability Plan of Sponsor Applied Remote Tech., Inc., 
    125 F.3d 794
    , 797 (9th Cir.
    1997). We review for clear error the district court’s underlying findings of fact.
    Friedrich v. Intel Corp., 
    181 F.3d 1105
    , 1109 (9th Cir. 1999).
    The district court did not err when determining whether Appellant’s stay at
    Sierra Tucson was “medically necessary,” as covered by the Plan. Appellant failed
    to show by a preponderance of the evidence that the treatment she received at
    Sierra Tucson was medically necessary or in compliance with United Healthcare’s
    applicable guidelines. Muniz v. Amec Constr. Mgmt., 
    623 F.3d 1290
    , 1294 (9th
    Cir. 2010) (explaining that it is the plaintiff’s burden to show that her treatment
    was medically necessary).
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    The Plan provides that “medically necessary” treatment is “[c]linically
    appropriate, in terms of type, frequency, extent, site and duration, and considered
    effective …”. The treatment must not be “mainly for [claimant’s] convenience or
    that of [their] doctor or other health care provider,” and must also not be “more
    costly than an alternative…service…”. Furthermore, medically necessary
    treatment must be “[i]n accordance with Generally Accepted Standards of Medical
    Practice,” which are based on clinical policies developed and maintained by United
    Healthcare. The Plan also provides that United Healthcare “reserve[s] the right to
    consult expert opinion in determining whether health care services are [m]edically
    [n]ecessary,” and that “the choice of expert and the determination of when to use
    any such expert opinion” is within United Healthcare’s “sole discretion.” UBH
    explained to Appellant’s husband that her treatment at the Sierra Tucson residential
    facility would be covered only if medically necessary. UBH also explained to
    Appellant that the Plan would only authorize her stay once she was evaluated and
    referred for residential treatment. Appellant informed UBH that she was not
    presently “in crisis or at risk.”
    Upon intake at Sierra Tucson, Appellant reported her primary problems as
    binge eating, isolation and poor body image. During her intake evaluation, treating
    physician Dr. Sipp noted that Appellant denied active suicidal ideation and had no
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    “plan or intent to harm herself or harm others.” UBH’s Dr. Uy reviewed
    Appellant’s intake evaluation for authorization and concluded that coverage was
    not available under the Plan, because she did not meet the level-of-care guidelines.
    Dr. Uy explained that because Appellant was stable and not presenting active
    suicidal ideation, she could be treated in a less restrictive care setting. When
    Appellant appealed Dr. Uy’s conclusion, UBH’s Dr. Sane found, as had Dr. Uy,
    that the level-of-care guidelines did not specify residential care for Appellant’s
    reported symptoms. Appellant had repeatedly denied suicide ideation, and it was
    not until after learning she was denied coverage that she expressed active suicidal
    thoughts. Specifically, Appellant threatened suicide if she was forced to leave
    Sierra Tucson.
    The district court appropriately considered Appellant’s assessments by Dr.
    Sipp and the UBH physicians. The district court was not required to defer to Dr.
    Sipp’s opinions, and the district court did not erroneously discount her opinions in
    its review of the record. Black & Decker Disability Plan v. Nord, 
    538 U.S. 822
    ,
    829 (2003) (explaining that in ERISA cases plan administrators do not need to
    accord special weight to the opinions of claimant’s physicians).
    AFFIRMED.
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