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

NOT FOR PUBLICATION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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