C. v. BlueCross BlueShield of Louisiana

UNITED STATES DISTRICT COURT

MIDDLE DISTRICT OF LOUISIANA

BRETT C., individually and on behalf CIVIL ACTION

of B.C., a minor,

VERSUS

BLUECROSS BLUESHIELD OF NO. 21-00589-BAJ-RLB

LOUISIANA, ET AL.

RULING AND ORDER

Before the Court is Plaintiffs Motion for Summary Judgment (Doc. 107,

“Plaintiff's Motion”). Defendants Louisiana Health Service & Indemnity Company

d/b/a Blue Cross and Blue of Shield of Louisiana (“BCBSLA”) and United Healthcare

Insurance Company and United Behavioral Health (collectively, “United”) oppose the

Motion. (Doc. 122; Doc. 123-1). In its Response in Opposition (Doc. 123-1), Defendants

United also requested a Judgment on Administrative Record, which the court

construes as a competing motion for judgment brought pursuant to Federal Rule of

Civil Procedure 52. Plaintiff filed Replies to both Responses in Opposition. (Doc. 128;

Doc. 129). Defendants United filed supplemental briefing (Doc. 131-1).

For the following reasons, Plaintiffs Motion will be DENIED, and judgment

shall be entered in favor of Defendants.

I. FACTUAL BACKGROUND

The following facts are drawn from Plaintiffs Statement of Material Facts

(Doc. 110-3), Defendant BCBSLA’s Opposition to Plaintiffs Statement of Material

Facts (Doc. 121), and Defendant United’s Responses to Plaintiffs Statement of

Material Facts and Statement of Additional Material Facts (Doc. 123-2). Plaintiff

Brett C. and his son B.C. had health insurance coverage through a fully-insured

employee welfare benefits plan (“the Plan”) covered by the Employee Retirement

Income Security Act of 1974, 29 U.S.C. § 1001, et seg. (“ERISA”). (Doc. 110-3 4).

BCBSLA was the relevant insurer, claims administrator, and fiduciary for Plaintiffs

Plan during the treatment at issue in this case taking place prior to February 1, 2021.

(dd. {| 2). After that date, United became the relevant insurer, claims administrator,

and fiduciary for Plaintiffs Plan. Ud. § 3).

B.C. suffers from Asperger's Syndrome, ADHD, and dysgraphia. He was

developmentally delayed and frequently had tantrums and outbursts. This led him

to begin attending therapy sessions, which was somewhat effective but did not fully

resolve his symptoms. Once he reached the eighth grade, B.C.’s school asked him to

leave and suggested that he attend an outside therapeutic facility that could more

_ fully meet his needs. (Doc. 110-3 § 4).

a. Care at Boulder Creek Academy

Between March 8, 2019, and April 16, 2019, B.C. received medical care and

treatment at Boulder Creek Academy (“BCA”). (Doc. 121 at 7-8). Plaintiff submitted

claims for the services rendered at BCA in March 2021. (Doc. 91-1 at 433). BCBSLA

rejected Plaintiffs claims for services provided at BCA because of “untimely filing”.

(Doc. 121 at 7-8). Plaintiff submitted an internal appeal with BCBSLA in May 2021,

which was denied for the same reason on June 17, 2021. (Id.; Doc. 91-1 at 458).

b. Care at Aspiro Wilderness Adventure Therapy

Between April 18, 2019 and June 25, 2019, B.C. received care at Aspiro

Wilderness Adventure Therapy (“Aspiro”). (Doc. 110-3 at 6-8). Defendant BCBSLA

disputes the characterization of care received by B.C. at Aspiro, defining it as

“outdoor youth treatment” rather than “medical treatment”. (Doc. 121 4 5; Doc. 110-

3 § 5). On August 10, 2021, BCBSLA rejected Plaintiffs claims for services provided

at Aspiro citing “Provider Type not eligible.” (Doc. 121 § 28). Plaintiff appealed this

benefits determination in an appeal to BCBSLA, and on July 13, 2022, the denial of

coverage was upheld. In its denial of the appeal, BCBSLA explained that Aspiro had

submitted a claim for “Psychiatric Residential” treatment but Plaintiffs benefits

required that service “to be provided by a facility that is licensed to provide this

service,” and that “Aspiro Adventure is not licensed for Residential treatment.” (Doc.

121 34).

c. Care at Elevations RTC

Between June 25, 2019 and November 19, 2019, B.C. received care at

Elevations RTC (“Elevations”). (Doc. 110-3 at 8-10). In July 2019, BCBSLA denied

Plaintiffs claims for services provided at Elevations because it had determined that

the treatment provided was not medically necessary. (Doc. 110-3 § 37). Plaintiff

appealed this determination in December 2019, but the claim was allegedly

misplaced by BCBSLA and not addressed until February 2021. (Doc. 121 at 12-18).

At that time, BCBSLA upheld the denial of these claims for lack of medical necessity.

(Doc. 121 ¥ 42). The denial letter gave the following reasoning for its determination:

Elevations RTC asked for approval to provide care for you. Your care

team provided us with information. You no longer required this level of

care. You were taking your medications. You reported that your

medications were working well for you. You denied side effects. You were

free of thoughts to harm anyone. Your mood had improved. You could

have been treated at a lower level of care. (Doc. 110-3 ¥ 48).

d. Care at Heritage School

Between November 20, 2019 and June 25, 2021, B.C. received care at Heritage

School (“Heritage”). (Doc. 110-3 at 10-15). On March 9, 2020, BCBSLA denied these

claims for the period during which it was the insurer. (Doc. 121 § 46). The Parties

dispute the characterization of the denial letter but agree that it included discussion

of medical necessity under the Plan. (Doc. 121 § 46; Doc. 110-3 | 46). Plaintiff

appealed this denial on February 8, 2021. The Parties dispute the characterization of

the contents of the appeal letter. Plaintiff contends that he included letters of medical

necessity with the appeal, and a review of the administrative record shows that he

did include some language allegedly from physicians who at some point in time were

involved with B.C.’s care, though the time period during which they were involved in

his care, as well as the time period these “letters of medical necessity” were written

and submitted, is of material dispute. (Doc. 110-3 at 11; Doc. 91-2 at 1666-68; Doc.

121 at 17; Doc 122 at 19 n.8).

After United became the insurer for the Plan, it denied payment for B.C.’s

treatment at Heritage between February 1, 2021, and June 25, 2021, through an

explanation of benefits that explained that the provider had not submitted required

information. (Doc. 110-3 ¥ 7; Doc. 128-2 ¥ 55). United alleges that its original benefits

determination was issued after several unsuccessful attempts at eliciting necessary

information from Heritage to process the claim. (Doc. 123-2 at 28-29). On November

16, 2021, Plaintiff sent a letter to United regarding this explanation of benefits, but

the parties’ disagreement over the characterization of this letter is at the heart of the

dispute. Plaintiff contends it was a “request for a retrospective review”. (Doc. 110-3

{ 54). United asserts that it constituted an appeal as defined by the Plan. (Doc. 128-

2 4 55). United responded to the letter on December 22, 2021, upholding the denial

of the claim because the facility “is classified as an ‘Authorization Unavailable’

facility”. It also concluded that “the expected service components consistent with the

guideline [United’s third-party claims reviewer] uses for Mental Health Residential

Treatment were not present,” and citing to the section of the guidelines referenced.

(Doc. 110-3 ¥ 57; Doc. 90 at 334). The denial letter also explicitly noted that “[t]his is

the Final Adverse Determination of your internal appeal. All internal appeals

through [United] have been exhausted.” (Doc. 110-3 4 57). On May 9, 2022, Plaintiff

submitted another letter to United. (Doc. 110-3 & 58). Again, the Parties disagree

regarding the characterization of this letter. Plaintiff contends this was an appeal.

United denies that it was an appeal because “Plaintiff already had exhausted all

internal appeals available under the Plan.” (doc. 123-2 § 58). United did not respond

to the letter. (Doc. 110-3 67; Doc. 123-2 ¥ 67).

II. PROCEDURAL BACKGROUND

Plaintiff filed suit in the U.S. District Court for the District of Utah pursuing

claims for recovery of benefits denied under ERISA § 502(a)(1)(B)

(29 U.S.C. § 1132(a)(1)(B)); or, alternatively, equitable relief under ERISA § 502(a)(8)

(29 U.S.C. § 1132(a)(8)). (Doc. 2; Doc. 36 §§ 68-95). Plaintiff asserts federal

jurisdiction pursuant to 28 U.S.C. § 1831 and 29 U.S.C. §1132(e)(1). (Doc. 2).

Defendant BCBSLA moved for transfer of venue to this Court under

28 U.S.C. § 1404(a), which was subsequently granted. (Doc. 18; Doc. 14). Defendants

moved to dismiss Plaintiffs claim for equitable relief under Federal Rules of Civil

Procedure 12(b)(6), which the Court denied. (Doc. 56; Doc. 60; Doc. 72). Nonetheless,

Plaintiff now pursues only the claim for recovery of benefits under

ERISA § 502(a)(1)(B) and does not pursue the second cause of action seeking

equitable relief. (Doc. 110-1). In accordance with Federal Rule of Civil Procedure

16(b), the Court issued a Case Order establishing deadlines for the Parties to file

motions for judgment based on the administrative record under Federal Rule of Civil

Procedure 52. (Doc. 77). Plaintiff instead moves the Court for summary judgment

pursuant to Federal Rule of Civil Procedure 56. (Doc. 110-1).

II. LEGAL STANDARD

a. Summary Judgment Standard

Plaintiff seeks summary judgment under Federal Rule of Civil Procedure

56(a), which provides that the Court may grant summary judgment only “if the

movant shows that there is no genuine dispute as to any material fact and the movant

is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). In determining

whether the movant is entitled to summary judgment, the Court views the facts in

the light most favorable to the non-movant and draws all reasonable inferences in

the non-movant's favor. Coleman v. Hou. Indep. Sch. Dist., 113 F.3d 528, 533 (5th

Cir. 1997). The Court, however, only “resolve[s] factual controversies in favor of the

nonmoving party ... only where there is an actual controversy, that is, when both

parties have submitted evidence of contradictory facts.” Antoine v. First Student, Inc.,

713 F.3d 824, 830 (5th Cir. 2013) Gnternal citation omitted) (emphasis added).

“Where the nonmovant bears the burden of proof at trial, the movant may

merely point to an absence of evidence, thus shifting to the nonmovant the burden of

demonstrating by competent summary judgment proof that there is an issue of

material fact warranting trial.” In re La. Crawfish Producers, 852 F.3d 456, 462

(5th Cir. 2017) Gnternal citation omitted). If the nonmoving party fails to provide

adequate support for their claims after being provided adequate time to conduct

discovery, “Rule 56(c) mandates the entry of summary judgment.”

Celotex Corp v. Catrett, 477 U.S. 317, 322-823 (1986). The Court is prohibited, in the

absence of evidence supporting each element of the claims alleged, from “assum|[ing]

that the nonmoving party could or would prove the necessary facts” at trial.

Little v. Liquid Air Corp., 37 F.8d 1069, 1075 (5th Cir. 1994).

Defendants United request judgment on the pleadings pursuant to Federal

Rule of Civil Procedure 52. (Doc. 26). Rule 52 requires the Court to “find the facts

specifically and state its conclusions of law separately.” Fed. R. Civ. P. 52. Courts

need not provide findings of fact on “all factual questions that arise in the case,”

Koenig v. Aetna Life Ins. Co., No. 4:18-CV-0359, 2015 WL 6554347, at *3 (S.D. Tex.

Oct. 29, 2015), nor must courts provide “punctilious detail nor slavish tracing of the

claims issue by issue and witness by witness.” Cent. Marine Inc. v. United States, 153

F.8d 225, 231 (5th Cir. 1998) (quoting Burma Navigation Corp. v. Reliant Seahorse

M/V, 99 F.3d 652, 656 (5th Cir. 1996)). Rather, Rule 52 is satisfied when the findings

“present the reviewer with ‘a clear understanding of the basis for the decision.”

Batchelor v. Life Ins. Co. of N. Am., 504 F. Supp. 3d 607, 610 (S.D. Tex. 2020) (quoting

Cent. Marine Inc. v. U.S., 153 F.8d 255, 231 (5th Cir. 1998)). “The findings and

conclusions may be stated on the record after the close of the evidence or may appear

in an opinion or a memorandum of decision.” Fed. R. Civ. P. 52. Here, the Court’s

findings of fact and conclusions of law will be provided in this Ruling and Order and

will be based solely on the administrative record and the parties’ respective briefs.

Because the only relevant facts in this case are found in the administrative

record, the Court’s ruling will satisfy both the Rule 56 standard for summary

judgment and Rule 52 standard for judgment on the administrative record.

b. ERISA

A person denied benefits under an ERISA plan has the right to challenge that

denial in federal court. Metro. Life Ins. Co v. Glenn., 554 U.S. 105, 108, 128 S.Ct.

2348, 2346 (2008). The standard of review for denial of benefits made by an ERISA

plan administrator is de novo “unless the benefit plan gives the administrator

fiduciary discretionary authority to determine eligibility for benefits or to construe

the terms of the plan.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109

S.Ct. 948, 956-57. The Parties do not dispute that the Plan vested Defendant

BCBSLA with discretionary authority to determine eligibility for benefits and to

construe and interpret the terms of the Plan. (Doc. 122 at 5-7; Doc 110-2 at 15). The

Court therefore reviews Defendant BCBSLA’s decision to deny Plaintiffs benefits

coverage on an abuse of discretion standard. See Jenkins v. Cleco Power, LLC, 487

F.3d 309, 314 (5th Cir. 2007).

Under an abuse of discretion standard, a plan administrator’s decision will

only be upset if the administrator acted in an “arbitrary or capricious manner in

denying benefits.” Id. (citing Matassarin v. Lynch, 174 F.3d 549, 563 (5th Cir. 1999)).

A decision is arbitrary when there is no “rational connection between the known facts

and the decision or between the found facts and the evidence.” Id. (quoting Bellaire

Gen. Hosp. v. Blue Cross Blue Shield of Mich., 97 F.8d 822, 828 (5th Cir. 1996)).

Plaintiffs carry the burden of proving an abuse of discretion. Nichols v. Reliance

Standard Life Ins. Co., 924 F.3d 802, 813 (5th Cir. 2019).

In reviewing a decision to deny or terminate benefits, courts are limited to the

administrative record and “may inquire only ‘whether the record adequately supports

the administrator’s decision.” Id. (quoting Gooden v. Provident Life & Acc. Ins. Co.,

250 F.3d 329, 333 (5th Cir. 2001)). The administrative record has been provided to

the Court. (Docs. 90, 91).

Adequate support is found when an administrator’s decision is supported by

“substantial evidence,” which is “more than a scintilla, less than a preponderance,

and is such relevant evidence as a reasonable mind might accept as adequate to

support a conclusion.” Anderson v. Cytec Indus., Inc., 619 F.3d 505, 512 (5th Cir. 2010)

(quoting Corry v. Liberty Life Assurance Co. of Boston, 499 F.3d 389, 398 (5th Cir.

2007)). Finally, a court’s review of a benefits decision need only conclude “that the

administrator’s decision fall[s] somewhere on a continuum of reasonableness — even

if on the low end.” Corry, 499 F.8d at 398 (quoting Vega v. Nat'l Life Ins. Serv., Inc.,

188 F.3d 287, 297 (5th Cir. 1999)).

However, unlike BCBSLA, United asserts that a de novo standard applies to

Plaintiffs claims against them without further elucidation. (Doc. 123-1 at 7). The

Court accepts this standard because it is the baseline for ERISA benefits review

except in narrow circumstances. Firestone Tire & Rubber Co., 489 U.S. at 115, 109

S.Ct. 948. “De novo review requires the court to apply the same standard as the plan

administrator in deciding whether the benefits were owed under the plan's terms.”

Krishna v. Nat'l Union Fire Ins. Co. of Pittsburgh, PA., 676 F. Supp. 3d 494, 502 (S.D.

Tex. 2023), aff'd sub nom. Krishna v. Nat'l Union Fire Ins. Co. of Pittsburgh,

Pennsylvania, No. 23-20289, 2024 WL 1049474 (5th Cir. Mar. 11, 2024).

The Court therefore reviews Defendant BCBSLA’s decision to deny Plaintiffs

claims under an abuse of discretion standard and Defendant United’s actions under

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a de novo standard. Under either standard of review, the Court is limited to the

administrative record in reaching its decision, and under either standard, the Court

reaches the same result. See Katherine P. v. Humana Health Plan, Inc., 959 F.3d 206,

207-08 (5th Cir. 2020); see also Jenkins, 487 F.3d at 314.

IV. DISCUSSION

a. Claims against BCBSLA

As discussed, the claims against BCBSLA will be reviewed under an abuse of

discretion standard. Plaintiff asserts an abuse of discretion due to substantive or

procedural deficiencies with BCBSLA’s benefits determinations for care provided at

BCA, Aspiro, Elevations and Heritage. The Court will address claims for each facility

in turn.

i. Denial of benefits for care at BCA

. Plaintiffs object to BCBSLA’s denial of benefits for care at BCA despite

acknowledging that the appeal was untimely filed 10 months after the 15-month

deadline to submit. (Doc. 110-2 at 18). Plaintiff attempts to invoke the “notice

prejudice rule” to make up for his lack of timeliness, but this argument is without

merit. The notice prejudice rule does not apply here because it is clear that a condition

precedent exists in the Plan that mandates adherence to the 15-month appeal

deadline. Peavey Co. v. M/V ANPA, 971 F.2d 1168, 1178 (5th Cir. 1992) (holding that

the notice prejudice rule in Louisiana applies only where timely notice is not an

express condition precedent). The relevant Plan language provides that “in no event

may any Claim be filed later than fifteen months from the date services were

rendered.” (Doc. 91-1 at 89). Plaintiffs argue that these terms do not create an express

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condition precedent. (Doc. 128 at 3). However, “[t]he term ‘express’ connotes that the

policy must clearly and explicitly connect compliance to coverage.” Morris v. State

Farm Fire & Cas. Co., 740 F. Supp. 3d 491, 502 (W.D. La. 2024). Here, BCBSLA

provides evidence of such a connection in the unambiguous written policy that

prohibits the filing of claims outside of the 15-month period. (Doc. 91-1 at 89).

Moreover, Plaintiff has failed to show that BCBSLA’s implementation of the 15-

month time limit was arbitrary or capricious and thus was an abuse of discretion to

warrant reversal of its benefits determination to the claims filed by Plaintiff for care

received at BCA.

ii. Denial of benefits for care at Aspiro

BCBSLA denied Plaintiffs claims for care received at Aspiro because it did “not

qualify as a covered provider under the Plan”. (Doc. 122 at 12). It further explained

in its July 18, 2022, letter denying Plaintiffs appeal that the facility was not licensed

to provide “Psychiatric Residential’ services as billed. (Doc. 110-2 at 7). Plaintiff

disagrees with BCBSLA’s interpretation of the Plan language as applied to Aspiro.

Specifically, Plaintiff alleges that Aspiro met the listed qualifications for a “provider”

and “Residential Treatment Center” because “there is no Plan requirement for

licensure of residential treatment facilities.” (Doc. 128 at 4). BCBSLA counters that

the Plan language explicitly requires providers to be “licensed where required,

performing within the scope of their license, and approved by the company,” citing to

the definition for “Provider” in Article II of the Plan. (Doc. 91-1 at 26).

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In reviewing ERISA cases, the Court must determine whether a plan

administrator’s interpretation was legally correct based on three factors, the most

important of which is whether the interpretation is consistent with a fair reading of

the plan. Stone v. UNOCAL Termination Allowance Plan, 570 F.3d 252, 258-60 (5th

Cir. 2009). A Plan should be interpreted “by the plain meaning of the plan language”

and in the “ordinary and popular sense as... a person of average intelligence and

experience” would. Crowell v. Shell Oil Co., 541 F.3d 295, 318 (5th Cir. 2008).

Plaintiff argues that the absence of the terms “licensed where required”

directly underneath the plan definition for Residential Treatment Center means that

no license is required. (Doc. 128 at 4). However, when read in context, it is clear from

the broader Plan provision regarding Providers generally that a licensing

requirement applies to all facilities and providers. (Doc. 91-1 at 26). Plaintiff points

to a definition for “skilled nursing facility or unit” that, lke the definition for

Residential Treatment Center, does not include an explicit licensing requirement in

the definition and contrasts this to the Plan’s definition for “Hospital”, which does

include such an explicit reference to licensing. (Doc. 128 at 3-4). However, licensing

is not explicitly mentioned in many other definitions in the plan glossary, including

for ambulatory surgical centers and urgent care centers, but there could be no serious

argument that the Plan’s broader licensing requirement for providers does not also

apply to these types of care providers. (Doc. 91-1, 17-28). BCBSLA’s interpretation of

its Plan language that eligible providers must be licensed and acting within the scope

of their license is not only defensible but persuasive. It follows the plain meaning of

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the plan language and is consistent with a fair reading of the Plan. BCBSLA’s

subsequent decision to deny Plaintiffs claims at Aspiro because of Aspiro’s failure to

meet the licensing requirements for the type of care it provided is thus not arbitrary

and capricious nor an abuse of discretion.

iii. Denial of Benefits for Care at Elevations

BCBSLA denied Plaintiffs claims for care provided at Elevations because it

was deemed not medically necessary. (Doc. 91-1 at 1204). Plaintiff asserts that

BCBSLA abused its discretion in denying these claims because BCBSLA “made

conclusory findings” and “did not refer to any of the information or arguments [he]

raised in his appeal nor did it refer to any specific medical records[.]’ (Doc. 110-2 at

20). Plaintiff further alleges that BCBSLA withheld from the claimants their

underlying rationale in reaching the conclusion that B.C.’s care was not medically

necessary. (Doc. 128 at 5).

However, BCBSLA did provide a rationale. In both of its denial letters,

BCBSLA stated “your care team reports your symptoms have improved, ... you are

getting along with staff and others. .. you are cooperative with treatment... you are

able to attend to your daily self-care needs.” (Doc. 91-1 at 1204). Importantly, this

rationale was supported by conversations with and reports from B.C.’s current care

team and BCBSLA’s independent peer reviewers, as well as B.C.’s own self-reported

symptoms. (Doc. 91-1 at 1010-1011, 1241, 1361).

Plaintiffs argument that BCBSLA’s determination must be reversed because

it did not respond to Plaintiffs alleged letters of medical necessity in its denial on

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appeal is unpersuasive. Plaintiff speculates that BCBSLA’s failure to specifically

reference these letters means that they were not considered by BCBSLA in its final

determination, but this is not supported. Plaintiffs letters are included in the

administrative record provided by BCBSLA. Moreover, “courts have no warrant to

require administrators automatically to accord special weight to the opinions of a

claimant’s physician; nor may courts impose on plan administrators a discrete burden

of explanation when they credit reliable evidence that conflicts with a treating

physician’s evaluation.” Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834,

123 S.Ct. 1965 (2008).

Plaintiff attempts to analogize his case to a recent 5th Circuit decision, Dwyer

v. United Healthcare Insurance Company, 115 F.4th 640 (5th Cir. 2024), in which an

insurer’s benefits determination was reversed for, among other reasons, failure to

engage in a “meaningful dialogue” under ERISA’s full and fair review standard. (Doc.

110-2 at 20-21). However, the facts of that case differ from the case sub judice.

Namely, in Dwyer, the Plan administrator’s denial of benefits was directly

contradicted by evidence in the administrative record that was available to the

administrator at the time of the patient’s treatment and associated benefits

determination. 115 F.4th at 647-48. That is not the case here, where the Court instead

finds support in the administrative record for BCBSLA’s denial of benefits for

Plaintiffs care at Elevations. (Doc. 122 at 17-18). Moreover, the Dwyer case applied

a de novo standard of review, not an abuse of discretion standard, as the Court applies

here. 115 F.4th at 646; Firestone Tire & Rubber Co., 489 U.S. at 115, 109 S.Ct. 948.

15

Taking into account only what is provided in the administrative record, the Plaintiff

has not met his burden to prove that BCBSLA abused its discretion in its

determination that B.C.’s care at Elevations was not medically necessary.

iv. Denial of Benefits for Care at Heritage

Plaintiff also takes issue with BCBSLA’s denial of benefits at Heritage because

“BCBSLA needed to communicate and explain which medical records it was relying

on to reach those conclusions.” Plaintiff cites no authority for this requirement, and

the Court finds no such requirement in the case law or federal ERISA regulations.

Rather, the relevant ERISA regulations require that an administrator must provide

“[t]he specific reason or reasons for the adverse determination” and “the specific plan

provisions on which the determination is based.” 29 C.F.R. § 2560.503-1(g)(1)(i), Gi).

Plaintiffs cite to Dwyer for a similar contention that BCBSLA was required to

specifically reference medical records and the letters of medical necessity submitted

by Plaintiff. 115 F.4th 630 (5th Cir. 2024); (Doc. 110-2 at 22). The Court disagrees.

Rather, in Dwyer, the Fifth Circuit notes that “[i]n the specific case of health benefits

denied on the basis of ‘medical necessity,’ a beneficiary is entitled to ‘either an

explanation of the scientific or clinical judgment for the determination, applying the

terms of the plan to the claimant’s medical circumstances, or a statement that such

explanation will be provided free of charge upon request.” Dwyer, 115 F.4th at 649-

50 (citing 29 C.F.R. § 2560.508-1(g)(1)(v)(B)). That Court found the defendant-

insurers denial of benefits insufficient in this regard because it did not offer an

16

explanation and did not mention the relevant plan provisions or how the insured’s

medical circumstances were evaluated under the plan. Jd. at 650.

Here, Defendant BCBSLA provided such an explanation in its denial letters.

It notified Plaintiff that the claim was denied because “care could be provided in a

less intensive restrictive setting” and “did not meet medical necessity [criteria]”. (Doc.

91-1 at 43808, 5189-5212). BCBSLA’s letters also referred to the relevant plan

provisions for determinations of medical necessity and to clinical information specific

to the Plaintiffs medical circumstances that is supported in the record by

conversations with B.C.’s providers at the time services were being rendered. (Id.)

(“You did not require daily medication monitoring”, “[y]ou were not described as being

in acrisis.”)) Further, both denial letters included a statement that an explanation of

the clinical judgment for the determination will be provided free of charge upon

request. (Doc. 91-2 at 1278, 2158). Plaintiff reiterates its argument that BCBSLA was

required to respond to or reference the letters of medical necessity Plaintiff included

in his appeal letter. (Doc. 128 at 7). For the same reasons discussed above regarding

the care provided at Elevations, the Court disagrees and finds that BCBSLA did not

abuse its discretion under ERISA’s full and fair review standard in its denial for care

provided at Heritage.

b. Claims against United

Plaintiffs claims against United relate to its denial of benefits for care at

Heritage and lack of response to Plaintiffs May 9, 2022, letter. The heart of the

17

dispute is whether this letter constitutes a valid appeal under the Plan terms. (Doc.

129 at 2; Doc. 123-1 at 7-8). The Court finds that it does not.

ERISA “requires only a single mandatory review.” DaCosta v. Prudential Ins.

Co. of Am., No. 10 Civ. 720 (JS) (ARL), 2010 WL 4722393, at *5-6 (E.D.N.Y. Nov. 12,

2010) (citing 29 U.S.C. § 11338(2)). Regardless of what title Plaintiff gave to his

November 2021 letter to United, it was a clear request for review of a post-service

claim denial that fits the definition for an appeal under the Plan terms. (Doc. 90 at

50-51, 199, 372). Plaintiffs arguments that insured parties are entitled to a

“retrospective review” is not supported by a reading of the Plan documents nor

relevant law.

Plaintiff asserts that “ERISA . .. regulations require an insurer to provide any

new rationale to the claimant prior to a final adverse decision,” but he does not

directly cite to any federal statute, regulation, or case law to support this contention.

(Doc. 129 at 4). Plaintiff further asserts that “[u]Jnder ERISA’s regulations, the family

was entitled to submit a follow-up appeal.” (/d.). The Court likewise does not find this

argument supported by the law. Plaintiff argues that “an administrator may rely on

new evidence or rationales to deny the claim so long as the claimant is given notice

and an opportunity to respond.” (Doc. 129 at 5). However, the specific section of the

ERISA regulations cited by the Plaintiff to support this contention applies only to

plans and claims for disability benefits, not healthcare plans. 29 C.F.R. § 2560.508-

1(h)(4)@-11). The relevance of Plaintiffs reference to ACA regulations in his reply brief

are not entirely clear and regardless will not be considered at this point in the

18

litigation due to inadequate briefing. See Willis v. Cleco Corp., 749 F.3d 314, 319 (5th

Cir. 2009). Further, Plaintiffs contention that Dwyer mandates United’s response to

his May 9, 2022, letter is inaccurate. (Doc. 129 at 6-7). Dwyer involved a plan

administrator ignoring a first request for appeal and then attempting to use post-hoc

rationalizations to defend its benefits determinations. 115 F.4th at 645, 650. The

instant facts differ notably in that United responded to Plaintiffs first appeal in

sufficient detail as described in the administrative record. As noted, ERISA mandates

only one level of internal appeal. 29 U.S.C. § 1133(2). The Court declines to review

United’s actions beyond the standards provided by those regulations. Thus, the Court

finds that United’s denial of Plaintiffs claim for care at Heritage did not violate

ERISA.

V. CONCLUSION

Accordingly,

IT IS ORDERED that Plaintiffs’ Motion For Summary Judgment

(Doe. 107) be and is hereby DENIED.

IT IS FURTHER ORDERED that Defendants United Healthcare

Insurance Company And United Behavioral Health’s Motion For Leave To

File Sur-Reply Brief In Opposition To Plaintiffs Motion For Judgment On

Administrative Record (Doc. 131) is GRANTED. The Court has considered

Defendants’ proposed sur-reply brief. The Clerk of Court shall enter Defendant’s

proposed sur-reply brief (Doc. 131-1) into the record under a separate docket entry.

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IT IS FURTHER ORDERED that Defendant BCBSLA’s Opposition to

Plaintiffs Motion for Summary Judgment (Doc. 122), which the Court

construes as a competing motion for judgment brought pursuant to Federal Rule of

Civil Procedure 56, be and is hereby GRANTED.

IT IS FURTHER ORDERED that Defendant United’s Response In

Opposition to Plaintiff's Motion and Request For Judgment on

Administrative Record (Doc. 120), which the Court construes as a competing

motion for judgment brought pursuant to Federal Rule of Civil Procedure 56, be and

is hereby GRANTED.

IT IS FURTHER ORDERED that Plaintiffs action be and is hereby

DISMISSED WITH PREJUDICE.

Judgment shall be entered separately.

Baton Rouge, Louisiana, mint, ofySeptember, 2025

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A.

JUDGE BRIAN A. JA N

UNITED STATES DISTRICT COURT

MIDDLE DISTRICT OF LOUISIANA

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