Case: 18-11105 Date Filed: 03/08/2019 Page: 1 of 10
[DO NOT PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT ________________________
No. 18-11105 ________________________
D.C. Docket No. 1:11-cv-23948-FAM
ALEXANDRA H.,
Plaintiff - Appellant,
versus
OXFORD HEALTH INSURANCE, INC.,
Defendant - Appellee.
________________________
Appeal from the United States District Court for the Southern District of Florida ________________________
(March 8, 2019) Case: 18-11105 Date Filed: 03/08/2019 Page: 2 of 10
Before WILSON, JILL PRYOR, and SUTTON, * Circuit Judges.
SUTTON, Circuit Judge:
Alexandra H. struggled with anorexia and undertook several types of
treatment for it. After she underwent a few weeks of “partial hospitalization” at a
specialized treatment facility in Miami, Oxford Health Insurance, the administrator
of her ERISA benefits plan, decided that this level of care was no longer medically
necessary and denied coverage for that level of treatment. Three administrative
reviewers upheld that decision. So eventually did the district court, which granted
summary judgment to Oxford. We affirm.
I.
Alexandra teaches elementary school in Brooklyn and is in her late thirties.
Since middle school, she has suffered from anorexia. She has been hospitalized
frequently and has tried many different types of treatments.
On December 14, 2010, she entered a “partial hospitalization” program at
Oliver-Pyatt, a Miami treatment center that specializes in eating disorders. The
center treated her for anorexia, obsessive compulsive disorder, and major
depressive disorder. She had 12 hours of therapy each weekday, spending
evenings and weekends on her own in a boarding facility.
* Honorable Jeffrey S. Sutton, United States Circuit Judge for the United States Court of Appeals for the Sixth Circuit, sitting by designation. 2 Case: 18-11105 Date Filed: 03/08/2019 Page: 3 of 10
After reviewing her symptoms, Oxford agreed to provide insurance coverage
for a few days of partial hospitalization. The insurance company’s medical
director, a psychiatrist, extended benefits twice after examining her treatment file
and speaking with her treating physicians. On January 4, 2011, however, the
medical director found that Alexandra had improved and recommended she
transition to a lower level of care, concluding that partial hospitalization was no
longer “medically necessary” under the employee benefits plan. Oxford denied
additional benefits for partial hospitalization at that point.
Alexandra challenged the decision, first proceeding through two levels of
internal appeal. Both of the reviewers, psychiatrists not previously familiar with
her case, upheld Oxford’s medical-necessity determination. Alexandra sought an
external appeal under New York law through the State of New York. The State’s
assigned independent reviewer, also a psychiatrist, agreed that partial
hospitalization was not medically necessary.
In 2011, Alexandra filed this ERISA action in the United States District
Court for the Southern District of Florida. The court determined that the benefits
plan’s terms precluded her from challenging medical necessity after the external
reviewer’s decision. This court disagreed and remanded the case to permit the
parties to determine whether “partial hospitalization” remained a medical necessity
at the time Oxford denied coverage. 833 F.3d 1299 (11th Cir. 2016). On remand,
3 Case: 18-11105 Date Filed: 03/08/2019 Page: 4 of 10
both sides moved for summary judgment. The district court granted Oxford’s
motion.
II.
We review an administrator’s decision to deny benefits under an ERISA
plan either with fresh eyes or for abuse of discretion depending on whether the
plan grants the administrator discretion. Firestone Tire & Rubber Co. v. Bruch,
489 U.S. 101, 115 (1989). The parties stake out different positions on the proper
standard of review. But that’s a thicket we need not enter, as the record supports
Oxford’s decision under either standard.
The plan defines “medically necessary” treatments as those that (among
other things) are offered at “[t]he most appropriate supply or level of services
which can safely be provided.” R. 130-1 at 113. A level of care remains medically
necessary, according to the plan’s level-of-care guidelines, if the patient “continues
to present with symptoms and/or history that demonstrate a significant likelihood
of deterioration in functioning/relapse if transitioned to a less intensive level” and
if she “cannot effectively move toward recovery and be safely treated in a lower
level of care.” R. 130-5 at 46–47.
Even if we review afresh the medical evidence before Oxford at the time of
its decision, Alexandra has not met her burden of showing that partial
hospitalization was still the most appropriate level of care on January 4, 2011. See
4 Case: 18-11105 Date Filed: 03/08/2019 Page: 5 of 10
Glazer v. Reliance Standard Life Ins. Co., 524 F.3d 1241, 1246–47 (11th Cir.
2008). The plan’s definition of medical necessity focuses on the stability of
improvement: Was the patient’s progress substantial enough that a step down in
treatment was unlikely to cause a setback?
Both considerations—stability of improvement and risk of setback—
animated Oxford’s decision. For the medical director and the reviewers who
upheld her decision, the benefits denial turned on two factors: the marked
improvement in Alexandra’s precipitating symptoms and the absence of dangerous
symptoms. See R. 130-5 at 36 (noting weight gain, meal completion, and
treatment compliance, and concluding that “ongoing personality-related issues . . .
can continue to be addressed in [intensive outpatient care]”); id. at 36–37 (noting
“improvements in the initial precipitating symptoms,” that “there no longer appear
to be such significant impairments,” and that “treatment could continue in a less
restrictive setting”); id. at 37 (noting “no serious risk of harm to self” or
“psychosis” and “the patient could safely be treated at a lower level of care”); see
also R. 130-3 at 32 (noting “psychiatric disturbances had improved and [she] did
not exhibit severe symptoms,” and concluding her “condition could be safely and
effectively managed at a lower level-of-care”). Because this evidence shows that
Alexandra could safely transition to less intensive care, it was fair to conclude that
partial hospitalization was no longer “most appropriate.”
5 Case: 18-11105 Date Filed: 03/08/2019 Page: 6 of 10
Confirming this conclusion is a look back, a comparative assessment of her
treatment status at the start of her partial hospitalization, in the middle of it, and at
the end of it. When Alexandra arrived at Oliver-Pyatt on December 14, she was
unable to gain weight, she was binging and restricting food, she was depressed,
and she reported passive suicidal ideation without intent or plan. A week later, on
December 20, she had gained a pound but was eating just fifty to seventy-five
percent of her meal plan.
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Case: 18-11105 Date Filed: 03/08/2019 Page: 1 of 10
[DO NOT PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT ________________________
No. 18-11105 ________________________
D.C. Docket No. 1:11-cv-23948-FAM
ALEXANDRA H.,
Plaintiff - Appellant,
versus
OXFORD HEALTH INSURANCE, INC.,
Defendant - Appellee.
________________________
Appeal from the United States District Court for the Southern District of Florida ________________________
(March 8, 2019) Case: 18-11105 Date Filed: 03/08/2019 Page: 2 of 10
Before WILSON, JILL PRYOR, and SUTTON, * Circuit Judges.
SUTTON, Circuit Judge:
Alexandra H. struggled with anorexia and undertook several types of
treatment for it. After she underwent a few weeks of “partial hospitalization” at a
specialized treatment facility in Miami, Oxford Health Insurance, the administrator
of her ERISA benefits plan, decided that this level of care was no longer medically
necessary and denied coverage for that level of treatment. Three administrative
reviewers upheld that decision. So eventually did the district court, which granted
summary judgment to Oxford. We affirm.
I.
Alexandra teaches elementary school in Brooklyn and is in her late thirties.
Since middle school, she has suffered from anorexia. She has been hospitalized
frequently and has tried many different types of treatments.
On December 14, 2010, she entered a “partial hospitalization” program at
Oliver-Pyatt, a Miami treatment center that specializes in eating disorders. The
center treated her for anorexia, obsessive compulsive disorder, and major
depressive disorder. She had 12 hours of therapy each weekday, spending
evenings and weekends on her own in a boarding facility.
* Honorable Jeffrey S. Sutton, United States Circuit Judge for the United States Court of Appeals for the Sixth Circuit, sitting by designation. 2 Case: 18-11105 Date Filed: 03/08/2019 Page: 3 of 10
After reviewing her symptoms, Oxford agreed to provide insurance coverage
for a few days of partial hospitalization. The insurance company’s medical
director, a psychiatrist, extended benefits twice after examining her treatment file
and speaking with her treating physicians. On January 4, 2011, however, the
medical director found that Alexandra had improved and recommended she
transition to a lower level of care, concluding that partial hospitalization was no
longer “medically necessary” under the employee benefits plan. Oxford denied
additional benefits for partial hospitalization at that point.
Alexandra challenged the decision, first proceeding through two levels of
internal appeal. Both of the reviewers, psychiatrists not previously familiar with
her case, upheld Oxford’s medical-necessity determination. Alexandra sought an
external appeal under New York law through the State of New York. The State’s
assigned independent reviewer, also a psychiatrist, agreed that partial
hospitalization was not medically necessary.
In 2011, Alexandra filed this ERISA action in the United States District
Court for the Southern District of Florida. The court determined that the benefits
plan’s terms precluded her from challenging medical necessity after the external
reviewer’s decision. This court disagreed and remanded the case to permit the
parties to determine whether “partial hospitalization” remained a medical necessity
at the time Oxford denied coverage. 833 F.3d 1299 (11th Cir. 2016). On remand,
3 Case: 18-11105 Date Filed: 03/08/2019 Page: 4 of 10
both sides moved for summary judgment. The district court granted Oxford’s
motion.
II.
We review an administrator’s decision to deny benefits under an ERISA
plan either with fresh eyes or for abuse of discretion depending on whether the
plan grants the administrator discretion. Firestone Tire & Rubber Co. v. Bruch,
489 U.S. 101, 115 (1989). The parties stake out different positions on the proper
standard of review. But that’s a thicket we need not enter, as the record supports
Oxford’s decision under either standard.
The plan defines “medically necessary” treatments as those that (among
other things) are offered at “[t]he most appropriate supply or level of services
which can safely be provided.” R. 130-1 at 113. A level of care remains medically
necessary, according to the plan’s level-of-care guidelines, if the patient “continues
to present with symptoms and/or history that demonstrate a significant likelihood
of deterioration in functioning/relapse if transitioned to a less intensive level” and
if she “cannot effectively move toward recovery and be safely treated in a lower
level of care.” R. 130-5 at 46–47.
Even if we review afresh the medical evidence before Oxford at the time of
its decision, Alexandra has not met her burden of showing that partial
hospitalization was still the most appropriate level of care on January 4, 2011. See
4 Case: 18-11105 Date Filed: 03/08/2019 Page: 5 of 10
Glazer v. Reliance Standard Life Ins. Co., 524 F.3d 1241, 1246–47 (11th Cir.
2008). The plan’s definition of medical necessity focuses on the stability of
improvement: Was the patient’s progress substantial enough that a step down in
treatment was unlikely to cause a setback?
Both considerations—stability of improvement and risk of setback—
animated Oxford’s decision. For the medical director and the reviewers who
upheld her decision, the benefits denial turned on two factors: the marked
improvement in Alexandra’s precipitating symptoms and the absence of dangerous
symptoms. See R. 130-5 at 36 (noting weight gain, meal completion, and
treatment compliance, and concluding that “ongoing personality-related issues . . .
can continue to be addressed in [intensive outpatient care]”); id. at 36–37 (noting
“improvements in the initial precipitating symptoms,” that “there no longer appear
to be such significant impairments,” and that “treatment could continue in a less
restrictive setting”); id. at 37 (noting “no serious risk of harm to self” or
“psychosis” and “the patient could safely be treated at a lower level of care”); see
also R. 130-3 at 32 (noting “psychiatric disturbances had improved and [she] did
not exhibit severe symptoms,” and concluding her “condition could be safely and
effectively managed at a lower level-of-care”). Because this evidence shows that
Alexandra could safely transition to less intensive care, it was fair to conclude that
partial hospitalization was no longer “most appropriate.”
5 Case: 18-11105 Date Filed: 03/08/2019 Page: 6 of 10
Confirming this conclusion is a look back, a comparative assessment of her
treatment status at the start of her partial hospitalization, in the middle of it, and at
the end of it. When Alexandra arrived at Oliver-Pyatt on December 14, she was
unable to gain weight, she was binging and restricting food, she was depressed,
and she reported passive suicidal ideation without intent or plan. A week later, on
December 20, she had gained a pound but was eating just fifty to seventy-five
percent of her meal plan. She struggled to engage in the program and refused to
see the psychiatrist. She was “very defeated,” “extremely tearful,” and “very
isolative.” R. 130-5 at 35. Although her treatment team’s notes from that week
indicated no suicidal ideation, Oxford’s medical director noted “some” after
speaking with Alexandra’s treating physician. Id. Seeing no improvement to
speak of, Oxford extended benefits for another week.
On December 27, Alexandra was “having difficulty” finishing her meals,
and she would restrict her food if left to herself. Id. She now cooperated with
treatment but was still depressed and guarded. Once again, the most recent
treatment notes said nothing about suicidal ideation, but Oxford’s medical director
reported that according to a therapist Alexandra still experienced some ideation.
Alexandra thus had improved from the previous week but not enough to make a
change in the intensity of treatment. Oxford extended benefits again.
6 Case: 18-11105 Date Filed: 03/08/2019 Page: 7 of 10
By the time Oxford denied benefits on January 4, Alexandra had turned a
corner. She had gained three pounds. According to her treating physician, she still
engaged in unusual eating rituals but, in the preceding week, had finished all of her
meal plan—even though the treatment team had increased the amount of food and
she had doubled her caloric intake over the last two weeks. She did not want
medication but otherwise complied with treatment. She was depressed but
“stable,” “alert,” “engaged,” and “not disconnecting” from treatment. Id. at 36.
She was reaching out to others in her therapy group. She had been able to care for
herself over the weekend, though she reported some depressive episodes. For the
first time, no suicidal ideation was noted.
When Oxford denied benefits, Alexandra had no symptoms indicating “a
significant likelihood of deterioration . . . if transitioned to a less intensive level of
care.” Id. at 46–47. She instead had improved on each front. Neither was there
any indication that she could not “effectively” and “safely” continue to recover
following a treatment step-down. Id. at 47. She was eating consistently and
improving emotionally even while looking after herself every evening and
weekend. Under the plan’s definition of “medically necessary,” Oxford could
deny benefits for continued partial hospitalization and recommend a transition to
intensive outpatient care and the fewer hours of therapy per day that came with it.
7 Case: 18-11105 Date Filed: 03/08/2019 Page: 8 of 10
Alexandra tries to counter this conclusion on several grounds. Relying on a
January 17, 2011, letter her doctors submitted in her second internal appeal, she
contends that Oxford’s assessment of her improvement was too rosy. In that letter,
her doctors insisted that she faced a grim regression if transitioned to outpatient
care, as she was “sporadically” failing to complete meals and still severely
depressed. R. 130-3 at 69. Setting aside the fact that the treatment records from
the week preceding Oxford’s decision seem to indicate she was completing all of
her meals, the point isn’t whether Alexandra was a picture of health. Neither is it
whether she was ready to stop treatment altogether. It is whether she had improved
so little that she continued to need the same kind of care as she had received for
three weeks or instead could handle a step down in treatment. In that same letter,
to that point, her doctors acknowledge her “marked progress,” noting that she was
exploring better responses to her disorder’s psychological triggers and was more
accepting of her nutritional needs and the difference between weight gain and real
recovery. Id. at 70.
Alexandra adds that she still experienced suicidal ideation at the time of
Oxford’s decision. But that concern is not reflected in the doctors’ records.
Oxford’s medical director noted suicidal ideation both times she extended benefits,
but there were no such reports the day Oxford denied benefits. No less
importantly, suicidal ideation, even had it still existed, would not automatically
8 Case: 18-11105 Date Filed: 03/08/2019 Page: 9 of 10
demand full-time treatment. Keep in mind what “passive suicidal ideation without
intent or plan” means: It refers to a situation in which the patient may think about
or wish for death but harbors no intent or plan to harm herself. Alexandra came to
Oliver-Pyatt with suicidal ideation and was nonetheless deemed a good fit for
partial hospitalization—a day-treatment program that leaves patients to their own
devices for half of every day and a program that all parties agree was appropriate
for her at the time. All of this confirms the essential distinction between having
suicidal ideation and intending or planning to commit suicide, the latter of which
would make a patient ineligible for either program and require more intensive care.
Alexandra notes last of all that she had tried outpatient treatment before and
it always failed. In support, she relies on her doctors’ letter, which emphasizes that
a history of premature treatment step-downs contributed to the chronic nature of
her illness. While Oxford’s guidelines treat a patient’s history as relevant to the
medical-necessity determination, an unsuccessful history is not dispositive or for
that matter very probative here. The fact that past step-downs were premature
proves nothing about this one, particularly given the doctors’ acknowledgement
that Alexandra had “greater conviction about her need to recover” this time and
that the care she received was strategically different from her prior treatments. R.
130-3 at 73. Plus, the guidelines mention a patient’s current symptoms in the same
9 Case: 18-11105 Date Filed: 03/08/2019 Page: 10 of 10
breath as her history. Alexandra’s earlier defeats did not establish her destiny for
this medical transition or any other.
AFFIRMED.