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9th Cir: Medical Necessity

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  • 9th Cir: Medical Necessity

    In a very straightforward opinion from the Ninth Circuit, the Appellant appeals the lower court's judgement in favor of the Defendant who found that the Appellant's residential treatment was not medically necessary. In a brief opinion, the court found that:

    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). 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…”.
    The opinion is attached below.
    Attached Files