Every major insurance company utilizes specific criteria to establish the appropriate medically necessary level of care during behavioral health treatment. But are such guidelines consistent with generally accepted standards for safe and effective treatment for psychiatric conditions?

A recent federal court ruling from Connecticut, S.B. v. Oxford Health Insurance Inc., 2019 WL 5726901 (D. Conn., Nov. 5, 2019), joined a rising chorus challenging the validity of guidelines developed by United Behavioral Health.

The plaintiff in S.B. was 16 years old when she was admitted to the Avalon Hills Eating Disorders residential treatment program after outpatient treatment had failed. Although the initial admission was approved by S.B.’s insurer, ongoing coverage was denied.

The plaintiff argued that care criteria developed by the American Psychiatric Association, or APA, were more consistent with accepted standards of medical care than the United Behavioral Health guidelines, but the insurance company disagreed.

Although the court concluded there was nothing improper about the development of treatment guidelines by insurance companies, the court began by addressing a significant problem with the defendant’s use of the United Behavioral Health, or UBH, guidelines:

“Under the UBH guidelines, a member of the plan may be admitted to residential treatment only to the extent that the ‘why now’ factors – that is, the ‘changes in the member’s signs and symptoms, psychosocial and environmental factors or level of functioning’ that ‘precipitated admission’ – cannot be ‘safely, efficiently and effectively treated in a less intensive level of care.’ (AR 1852.)

“Thus, it appears that under the UBH guidelines, even if a member’s underlying condition will not improve without residential treatment, such treatment is not authorized unless the treatment is necessary to address the ‘why now’ factors – the particular ‘changes’ or symptoms that ‘precipitated admission.'”

It is largely this feature of the guidelines that led one court to conclude that the UBH guidelines were arbitrary and capricious in themselves. Wit v. United Behavioral Health, 2019 WL 1033730, at *22 (N.D. Cal., March 5, 2019) (finding that the UBH guidelines show ‘an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions.’).

The court thus found the UBH factors conflicted with plan terms because of a “general bias … toward crisis management … rather than the effective and otherwise medically necessary treatment of the underlying condition.”

Further, the court was critical of UBH’s failure to respond to Avalon’s concern that treatment of S.B. at lower levels of care would likely be ineffective and that approving care solely for stabilization of acute symptoms is inadequate because it fails to address the underlying condition.

Although the insurer’s doctors maintained the plaintiff was compliant with treatment, the clinic records contradicted that conclusion and demonstrated only partial compliance at best. The court further noted that compliance under the APA guidelines was merely an indication of proper placement. Noncompliance would suggest the need for a higher level of care.

The court also zeroed in on the issue of S.B.’s “overall motivation to recover,” which was poor since the plaintiff was oppositional and showed insufficient insight into the problems that led to her residential treatment admission.

“Under the APA guidelines,” the court added, “‘poor-to-fair motivation’ is an indication for residential treatment, while ‘partial motivation’ is an indication for partial hospitalization. (AR 608.) The only conclusion with support in the record is that [p]laintiff’s motivation was ‘poor-to-fair’ and the more likely conclusion is that it was closer to ‘poor’ than ‘fair.'”

Other issues recognized by the court as undermining the insurer’s conclusion was S.B.’s need for supervision at all meals to prevent restriction of eating. The court additionally pointed out that the UBH reviewers’ comments about S.B.’s ability to take care of her personal needs and attend therapy and other programming was misleading.

Under the APA guidelines, taking care of personal needs is not a relevant consideration in determining a recommended level of care. The court was similarly critical of the UBH reviewers’ reliance on S.B.’s participation in a skiing trip and a zumba class because the records showed a lack of actual participation, thus leading to the following comment: “The ability to do little more than go for a ride and walk seems largely irrelevant to the appropriate level of care for [p]laintiff’s eating disorder and using this fact to explain the denial of coverage for [p]laintiff’s residential treatment is misleading in light of Avalon’s explanation.”

The court was equally dismissive of UBH’s reliance on a lack of evidence of suicidal thoughts or behavior. Nor was the court persuaded that records showing that S.B. had gained weight during her treatment supported the insurance company’s determination. The court cited the APA guidelines for the proposition that “[p]atients need to both gain healthy body weight and learn to maintain that weight prior to discharge…” (emphasis added), and “patients should not be automatically discharged just because they have achieved a certain weight level unless all other factors are appropriately considered.” Since that was not established here, the court found UBH’s determination was arbitrary.

Hence, due to overwhelming evidence that the plaintiff was not ready for discharge from residential treatment, the court found the removal of support for treatment was premature.

The court faulted UBH’s medical consultants for ignoring the treating doctors’ warning of a significant risk of relapse if residential treatment ended too early, especially since the plaintiff denied she even had a problem.

The court also rejected UBH’s medical consultants’ findings that the claimant was “doing better” as conclusory and lacking a sufficient rationale without further supporting evidence. Thus, the court remanded the case to UBH for reconsideration.

The value of this opinion was in the court’s willingness to address why UBH’s guidelines were inadequate and inconsistent with the standard of medical care.

The court recognized the fatal flaw in the UBH guidelines’ focus on treating acute symptoms rather than the underlying problem and was then able to dissect the rubber-stamp approach taken by the UBH reviewing doctors and explain why their opinions were deficient.

Hence, the entire picture added up to an arbitrary denial of benefits.

This article was initially published in the Chicago Daily Law Bulletin.

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