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Terrible Plaintiff Mental Health In-Patient Stay Opinion – E.D.N.Y.

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  • Terrible Plaintiff Mental Health In-Patient Stay Opinion – E.D.N.Y.

    Terrible Plaintiff Mental Health In-Patient Stay Opinion – E.D.N.Y.

    Attached is a case out of the Eastern District of New York, Halburg v. United Behavioral Health. In the case, plaintiff’s claim relates to inpatient mental health treatment for his minor child. The minor had a history of self-harm, and while in inpatient care she had several incidents of self-harm necessitating hospitalization. Additionally, even though the minor was restricted from all sharp objects, the minor would seek objects out and left the facility, at least twice, in search of objects to harm herself with. While in inpatient care she continued to exhibit suicidal ideation, but the symptoms were less pronounced. Plaintiff submitted several statements from the minor’s physicians stating if she was not treated at this level of care there was a very high probability that she would attempt suicide if she returned home. Defendant denied the claims asserting that inpatient care was not medically necessary. Plaintiff appealed the denial, fully exhausted administrative remedies, and instituted litigation. The court found that defendant did not abuse its discretion in denying the claims. The plaintiff has filed an objection to the report and recommendation of the magistrate.

    Plaintiffs spend much energy in their papers identifying evidence in the administrative record that is in tension with UBH’s (and the independent reviewer’s) determination to deny coverage. For example, Plaintiffs argue that “UBH’s determination that the care C.H. received at 3East was ‘not medically necessary’ is contradicted by C.H.’s medical records [and] the medical opinions of her treating providers,” (Pls.’ Supp. Br. at 9), and that:

    UBH’s determination was clearly erroneous in light of the extensive evidence that C.H. required the structure of residential care in order to progress in her treatment and avoid additional attempts to take her own life. In the face of evidence that C.H. was persistently threatening suicide, engaging in self-harm, running away from her program, and refusing medication and other treatment, UBH blithely contended that she was free of significant mood disorders and could be safely managed in an outpatient setting.

    (Id. at 10).

    To be sure, Plaintiffs have cited to record evidence that is in tension with these conclusions and suggest a different result could have been reached by the UBH administrators. But that is not sufficient for Plaintiffs to prevail. “[I]f the administrator has cited substantial evidence in support of its conclusion, the mere fact of conflicting evidence does not render the administrator’s conclusion arbitrary and capricious.” Elizabeth W. v. Empire HealthChoice Assurance, Inc., 709 F. App’x 724, 727 (2d Cir. 2017) (quotations omitted). In this context, “[s]ubstantial evidence . . . is such evidence that a reasonable mind might accept as adequate to support the conclusion reached by the decisionmaker and requires more than a scintilla but less than a preponderance.” Miller v. United Welfare Fund, 72 F.3d 1066, 1072 (2d Cir. 1995) (quotations and alterations omitted). “In short, the question is not whether the record would have permitted a plan administrator to find otherwise, but whether the record compelled the different conclusion urged by [plaintiff].” Kruk v. Metro. Life Ins. Co., 567 F. App’x 17, 20 (2d Cir. 2014).

    On the bases of these records and evidence UBH repeatedly concluded that C.H.’s stay at 3East was not necessary or appropriate under the governing care guidelines and she could be treated effectively at a lower level of care:
    • “The services that you received [at 3East] do not appear to be consistent with generally accepted standards of practice based upon the applicable guideline. There was significant improvement and you were allowed to go on passes with family and runs without supervision. At times, your attending physician did not examine you for weeks which would indicate you were much improved. . . . Care could have continued with outpatient providers, which is a covered benefit and is available locally.” (Ex. 4 UBH Letters at 515 (2/15/13 Letter) (indicating decision based on the “a review of the behavioral health services that you received, the review of the Summary Plan Description for Axa Equitable, review of UBH Coverage Determination Guidelines for Residential Treatment of Major Depressive Disorder, and a review of the medical records”)).

    • “I have determined that the services you were receiving were not consistent with generally accepted standards of medical practice for the noted symptoms at this level of care. . . . [Y]ou were able to work well with your treatment team on your recovery goals and seemed more like yourself and interacting positively with others. You did not appear to have serious mood problems that couldn’t be managed in a less intensive setting. You did not have additional medical or substance usage issues requiring 24-hour monitoring and nursing care. . . . [T]reatment could have occurred in a less intensive setting[.]” (Id. at 27–28 (3/22/13 Letter) (indicating decision based on “review of your Summary Plan Description, review of UBH Coverage Determination Guideline for Major Depressive Disorder and Dysthymic Disorder, and benefit request letter and medical records”)).

    • “[Y]ou were able to work with your treatment team on your recovery goals; you were more positive in relationships with others. You did not appear to have significant mood symptoms or thought disturbance requiring 24-hour monitoring and nursing care. You were able to attend multiple activities and passes. You were able to manage your daily activities and make decisions about treatment. It appears that you had achieved maximum benefit from the residential setting and that you no longer required 24-hour monitoring and treatment.” (Ex. 5 UBH Letters at 190 (8/16/13 Letter) (indicating review of “Medical Record(s),” “[t]he letter requesting an appeal,” and “[c]are management records”).

    • “[Y]ou were able to work with your treatment team on your recovery goals by attending programming and taking your medications. You seemed more like yourself and were able to manage your day-to-day tasks. You were not acting on every thought/feeling. You were able to attend multiple activities outside the facility as well as multiple day passes.” (Ex. 4 UBH Letters at 22 (10/30/2013 Letter) (indicating review of facility medical records, the SPD, and the UBH Coverage Determination Guideline for Major Depressive Disorder)).

    • “[Y]ou were actively participating in treatment. There was no evidence of an imminent risk of harm to self or others. . . . You were generally able to attend all facility activities and passes. It appeared that you had achieved maximum benefit at the residential level of care.” (Ex. 5 UBH Letters at 297 (11/15/2013 Letter) (indicating review of “Medical Record(s),” “[t]he letter requesting an appeal,” and “[c]are management records”)).

    • “The record shows you were not exhibiting any behavioral problems that required this level of structure and monitoring. Overall, your mood appeared stable. You were not engaging in any self-harm behaviors during this period. You were generally attending groups and taking your medication. There was no indication that you could not tolerate treatment in a less intensive setting. You were able to adequately handle off-unit activities including overnight passes. You did not have any complicating medical or substance use problem that would not allow treatment at a lower level of care. The intensity of your treatment did not match the intensity of your condition[.]” (Id. at 2 (2/14/2014 Letter) (indicating review of “medical records, case records and a letter of appeal”)).

    These decisions are within the discretion of the UBH administrators. UBH’s guidelines for coverage state that the plan does not cover mental health services that “in the reasonable judgment of the Mental Health . . . Administrator are” “not clinically appropriate for the patient’s Mental Illness . . . based on generally accepted standards of medical practice and benchmarks” or “not consistent with generally accepted standards of medical practice for the treatment of such conditions.” (UBH SPD at 7399). Such an exclusion applies “even if [the services] are recommended or prescribed by a provider or are the only available treatment for your condition.” (Id. at 7397).14

    These are also, with little doubt, conclusions supported by substantial evidence. The record contains evidence that while C.H. was at 3East (while paying for her stay), C.H.’s suicidal symptoms were less pronounced, (Admin. R. 5874 (risk assessment indicates suicidal ideation was intermittent with no specific plans)); that her mood showed positive and bright affect, (id. at 1066, 6293 (case summary) (“The member often reported having a positive mood. The member was socializing and had bright affect reported in multiple notes.”)); and that she was positively engaged with her caregivers, motivated, and focused on her treatment plan, (id. at 49, 84). Other records indicated that C.H. showed significant improvement in mood and symptoms and she developed the ability to leave the facility on day passes for multiple days at a time throughout her stay. (See supra p. 10; e.g., Admin. R. at 50 (“[Patient] . . . socialized with staff and peers. . . . [Patient] appeared in euthymic affect throughout dinner.”); id. at 74 (“[Patient] appeared euthymic in her interactions with staff and residents”) (describing C.H. as “Active/Involved” in her group therapy session); Def.’s 56.1 Stmt. ¶¶ 37–38; Pls.’ 56.1 Resp. ¶¶ 37–38).

    While there is evidence Plaintiffs can point to that supports their position, that does not mean that UBH acted in an arbitrary and capricious manner, and UBS’s ultimate conclusion to deny coverage is certainly supported by more than a scintilla of evidence in the record.15

    This case is similar to the Court’s resolution in E.R. v. UnitedHealthcare Insurance Co., 248 F. Supp. 3d 348 (D. Conn. 2017). In E.R., the Court affirmed UBH’s denial of coverage for inpatient treatment for the Plaintiff’s eating disorder, and the Court rejected plaintiff’s view that residential care was “medically necessary,” notwithstanding evidence that “Plaintiff had continued to over[-]exercise, had a complicated family medical history and life at home, struggled to comply with her meal plan requirements at times, was not fully motivated to recover, required structure and monitoring, and suffered from bradycardia and othorstatic hypotension around the time of, or within a few weeks prior to, UBH’s decision.” 248 F. Supp. 3d. at 367. The Court affirmed the benefits denial because the administrative record contained evidence that supported a reviewer’s conclusion that the Plaintiff: “(1) was not a risk of harm to herself or other[s], (2) had no medical issues, (3) had reached an appropriate weight, (4) was participating in her recovery, (4) tolerated several out-of-state passes, (5) did not need 24-hour supervision, and (6) could have been safely treated at a less restrictive level of care such as partial hospitalization.” Id. at 366; see also Stemme v. Blue Cross Blue Shield of Kan. City, No. 11-CV-2635, 2013 WL 12362335, at *7 (N.D. Tex. Feb. 25, 2013) (granting summary judgment when “evidence demonstrates that the individuals who reviewed BCBS’s initial decision to deny Stemme’s claim considered Stemme’s evidence but concluded that the opposing evidence was more persuasive.”). As in these cases, while there is evidence C.H. had suicidal ideation at times and medical records showed a worsening mood, there is a multitude of evidence, relied upon by UBH, that suggests that C.H. had made significant progress, had improved mood, was not suicidal, and due to those improvements did not need to be in a full-time residential facility for a 16- month period. And when she was in need of a stepped-up level of care, she was hospitalized and provided care at 2East, which was covered by UBH. Although one could draw a different conclusion based upon medical records, that is certainly not sufficient for a reviewing court to conclude that UBH was acting outside of its considerable discretion in denying coverage. And “[e]ven if the evidence supporting [Plaintiffs’] position were more convincing than the evidence supporting [UBH’s], there is nonetheless more than a scintilla of evidence supporting [UBH’s] conclusion, and a reasonable mind might accept that evidence as adequate to support that conclusion. There is thus substantial evidence supporting [UBH’s] position.” Stemme, 2013 WL 12362335, at *7.
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