Kimberley D. v. United Healthcare Insurance Co.

          STATEMENT OF DECISION PURSUANT TO FED.R.CIV.P. 52

          Jeffrey T. Miller, United States District Judge

         INTRODUCTION

         On May 5, 2015, Plaintiff Kimberley D. commenced this Employee Retirement Income Security Act (“ERISA”) action seeking damages for Defendant United Healthcare Insurance Company’s (“UHIC”) alleged breach of the LifeLock, Inc. Welfare Benefit Plan (“Plan”). Plaintiff broadly alleges that she has a 30-year history of mental illness consisting of major depressive disorder, generalized anxiety disorder, borderline personality disorder, and an eating disorder. When Plaintiff, a San Diego resident, self-referred to an Arizona residential treatment center, Sierra Tucson, for treatment of escalating depression and worsening eating disorder associated with life stressors, UHIC, through the mental health benefits administrator, United Behavioral Health (“UBH”), determined that inpatient treatment was not medically necessary as that term is defined in the Plan. Plaintiff alleges that the denial of the medically necessary treatment violated the Plan.

         The parties agree that the de novo standard of review applies to Plaintiff’s claims. The parties also agree to the contours of the evidentiary record submitted by the parties. Based upon the parties’ submissions, the issue before the court is simply whether the inpatient residential treatment received by Plaintiff was medically necessary under the circumstances of this case and, therefore, a covered benefit under the Plan. Having carefully considered the matters presented, the court record, appropriate legal authorities, and the arguments of counsel, the court concludes that Plaintiff fails to show that UHIC breached the Plan.

         FINDINGS OF FACT

         Plaintiff’s Medical History

         Plaintiff is a 51-year old woman with a history of mental illness and eating disorders. On April 22, 2013, Plaintiff was admitted to the Eating Disorder Center of San Diego (“EDCSD”) and diagnosed with bulimia nervosa, and secondary diagnoses of major depressive disorder, recurrent, severe without psychotic features and posttraumatic stress disorder. (UBH 1441). The EDCSD report indicates the following symptoms: “binge eating daily; restricts all day, binges at night, gained 35 pounds since last October; using enemas and laxatives 2-3 times week; panic attacks; obsessing about food in house and hypervigilant.” (UBH 1442). The report indicated that Plaintiff was not at imminent risk to herself or others. Id.

         From April through August 2013, UBH authorized Plaintiff to receive 33 intensive outpatient sessions at out-of-network EDCSD to focus on her eating and related disorders. After discharge, Plaintiff underwent an additional 30 outpatient treatment sessions with focus on her eating and related disorders. Plaintiff received these treatments periodically through May 2014.

         Admission to Sierra Tucson

         On May 6, 2014, Plaintiff’s husband called UBH and stated that a therapist suggested that Plaintiff receive inpatient treatment at Sierra Tucson. The cryptic notes from the telephone conversation indicate that the UBH representative informed Plaintiff’s husband that inpatient residential treatment was available upon showing medical necessity. The term medical necessity was explained to Plaintiff’s husband. On May 8, 2014, Sierra Tucson called UBH to inquire about coverage and was informed that authorization was required for inpatient treatment.

         On May 9, 2014, UBH called Plaintiff and inquired about her status and whether she needed assistance. The notes indicate that Plaintiff was not in crisis or at risk. Plaintiff reported that she was having difficulty coping with her home life and her eating order symptoms were “very hard to manage.” Plaintiff also stated that her therapist recommended placement in Sierra Tucson, a residential inpatient facility, to treat her symptoms and mood/coping abilities. Plaintiff also informed the UBH representative about an “escalating home situation” involving her son and his girlfriend. The representative also suggested that Plaintiff consider a facility closer to her home in San Diego, California.

         The Initial Psychiatric Evaluation by Sierra Tucson

         On May 13, 2014, without authorization for residential treatment, Plaintiff admitted to Sierra Tucson for inpatient residential treatment where she received a psychiatric evaluation by Dr. Nia Sipp, a psychiatrist. The evaluation noted: CHIEF COMPLAINT: "...I was looking for treatment for my son's girlfriend and I thought maybe I could go to treatment myself..." (UBH 188). The HISTORY OF PRESENT ILLNESS section of the evaluation identifies that Plaintiff’s eating disorder symptoms have increased with “life stressors.” The “life stressors” consist of her then present living situation. Plaintiff’s son and his girlfriend lived with Plaintiff as did her husband. She identifies that the girlfriend is “deliberately manipulative, ” mentally ill, and engages in damaging behavior. Both her son and the girlfriend are heroin addicts and her husband was in treatment for alcohol use disorder. The girlfriend injured herself and then falsely reported to the police that the son had injured her and threatened to also falsely tell the police that the entire family was involved with her injury. The husband moved out of the home to avoid the false allegations and Plaintiff commenced a legal action against the girlfriend to effectuate her removal from the home. The HISTORY section concludes:

Patient endorses depressive and anxious symptoms at this time along with SI (Suicide Ideation). Patient denies psychotic symptoms. She denies active SI and denies HI (Homicidal Ideation). Patient has no[] plan or intent to harm herself or harm others.

(UBH 0188).

         Under the PSYCHIATRIC SYMPTOMS section, Dr. Sipp set forth the following evaluation:

Depression: Pt. first experienced depressive symptoms as a child. She did not like school and often complained of somatic symptoms in an attempt to “disappear in school...” Pt. has had three severe depressive episodes as an adult in 2002, 2005 and 2012. She feels her current depressive episode is the most severe of the episodes. Her current depressive symptoms are characterized by hyper somnolence, low energy, anhedonia, carbohydrate cravings, feeling that her legs feel like “ weights,, .”, poor motivation, poor memory, low mood, feelings of worthlessness and hopelessness, recurrent wishes that she was someone else, passive and active suicidal ideation. Pt. has also had periods where she was unable maintain appropriate hygiene and grooming while depressed. Pt.’s passive and active SI during her treatment at EDCSD resulted in multiple safety assessments and welfare checks. Bipolar Spectrum symptoms: Denies.

         Under the PSYCHIATRIC HISTORY section, the subheading identified as Suicide attempts, the evaluation indicates that, in “2002, patient lost 70 lbs and was severely depressed with increased suicidal ideation. Patient denies that she made a suicide attempt at that time.” (UBH 189).

         Under the MENTAL STATUS EXAM section, Dr. Sipp noted:

This is a well-developed, well-nourished female in no acute distress. Pt, is tearful during evaluation. She is alert and oriented x 4, Her hygiene and grooming are intact. Her eye contact is well maintained. There are no psychomotor abnormalities observed. Her pace of speech, rhythm of speech and speech pattern are within normal limits. Her mood is anxious. Her affect is congruent with mood and full range. Her thought process is circumstantial and tangential. Her thought content is devoid of suicidal ideation or homicidal ideations. She denies current intent or plan to commit suicide or harm herself. She denies perceptual disturbances and there is no evidence of psychosis. Insight and judgment are fair and improving. Attention and concentration are intact. Cognition is grossly intact, but was not formally tested.

         Dr. Sipp diagnosed Plaintiff with generalized anxiety disorder, major depressive disorder recurrent severe, panic disorder, and borderline personality disorder. While Plaintiff argues that Sierra Tucson identified that Plaintiff had made an earlier suicide attempt at some unidentified point in time, (Opening Br. at p.5:22), the evaluation states that, at the time of admission, Plaintiff’s “thought content is devoid of suicidal ideation or homicidal ideations. She denies current intent or plan to commit suicide or harm herself.” (UBH 191).

         Suicide Risk and Suicide Ideation

         The medical records in this case contain references to suicide ideation (passive or active), suicide attempts, suicidality, suicidal thoughts, and suicide risk. Many of these reference seem to be invoked without definition, context, or explanation. Notwithstanding, this court is able to make some observations and findings regarding the general subject of suicide risk:

(1) At no time prior to her stay at Sierra Tucson, beginning in May 2015, is there any evidence Plaintiff ever attempted suicide.

(2) Although Plaintiff was initially evaluated at a “high” risk suicide level (at a 10-12 on a scale of 20), this initial risk level was not supported by either Plaintiff’s chief complaint or history. Specifically Plaintiff presented with depression, worsening eating disorder and life stressors based upon her home environment. She denied active SI and was not planning to harm herself or others. Significantly, there is no ...