Clauss v. Plan

196 F. Supp. 3d 463, 2016 WL 3940714, 2016 U.S. Dist. LEXIS 95195
CourtDistrict Court, M.D. Pennsylvania
DecidedJuly 21, 2016
DocketCIVIL ACTION NO. 3:14-CV-00889
StatusPublished
Cited by6 cases

This text of 196 F. Supp. 3d 463 (Clauss v. Plan) is published on Counsel Stack Legal Research, covering District Court, M.D. Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Clauss v. Plan, 196 F. Supp. 3d 463, 2016 WL 3940714, 2016 U.S. Dist. LEXIS 95195 (M.D. Pa. 2016).

Opinion

MEMORANDUM

EDWIN M. KOSIK, DISTRICT JUDGE

Plaintiff filed the instant action pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”). Plaintiff’s complaint alleges that she is a participant in the Geisinger Quality Options, Inc., Health Plan (the “Health Plan”) administered by Defendant, and that Defendant wrongly denied her benefits due to her under the terms of the Health Plan. Presently before the Court is Defendant’s Motion for Summary Judgment. Although Plaintiff did not file a motion for summary judgment, in her brief, she requests judgment in her favor and against Defendant. (Doc. 27, Pitt’s Br., at 15). Accordingly, we will treat the case as if cross-motions for summary judgment were filed. Sexton v. Group Long Term Disability Plan for Employees of Inmar Enterprises, Inc., Civ. No. 04-2475, 2006 WL 559908, at *1 (M.D.Pa. March 7, 2016).

I. Background

Plaintiff, Alice Clauss, was employed as an Assistant Art Director at The Paper Magic Group, Inc., (“Paper Magic”) since 2010. (Doc. 22, Def.’s SOF, at 1 and 2; Doc. 26, Pitt’s Answer to SOF, at 1). Until 2013, Paper Magic provided its employees with group medical insurance coverage through Independence Blue Cross (“Blue Cross”). (Doc. 26, at 1). However, in September of 2013, Paper Magic contracted with Geisinger Quality Options, Inc., to provide its employees with group medical insurance coverage. (Doc. 22, at 2; Doc. 26, at 2).

Plaintiff was diagnosed with Myasthenia Gravis1 (“MG”) and Myasthenia Gravis with exacerbation. (Doc. 22, at 5; Doc. 26, at 5). Her neurologist, Scott M. Frieden-berg, M.D., had submitted to her prior medical insurance provider, Blue Cross, a request for pre-approval of biweekly intravenous immunoglobulin (“IVIG”) treatments. This treatment course was opined to be necessary by Dr. Friedenberg and Dr. Joseph Shovlin, Plaintiffs optometrist, because without IVIG treatment, the only other drug alternatives to treat Plaintiffs MG produced not only undesired results, but would eventually cause Plaintiff to develop subretinal neovascularization, resulting in her permanent loss of vision. (Doc. 23, Def.’s Ex. A To Def.’s Memorandum, at [467]*467176 and 190). Further, both Dr. Frieden-berg and Dr. Shovlin provide that Plaintiff did well with the IVIG therapy, which allowed them to decrease the drug Predni-sone. (Id. at 152). Plaintiffs physicians opine that if IVIG therapy is not approved, then Plaintiff would be forced to increase her Prednisone to control her MG, which will result in the permanent loss of her vision. (Id. at 152 and 176).

When Paper Magic switched its medical insurance provider from Blue Cross to Defendant, Plaintiffs doctors again sought pre-approval for biweekly IVIG treatments. (Doc. 22, at 6 and 9; Doc. 26, at 6 and 9; Doc. 23, Def.’s Ex. A, at 129). In response, Defendant authorized a single IVIG treatment pending consideration of Plaintiffs request for pre-approval of IVIG treatments. (Id). To assist in determining whether IVIG was medically necessary in treating Plaintiff, Defendant sought an independent medical review from AllMed Healthcare Management (“AllMed”). (Doc. 22, at 10; Doc. 26, at 10). The AllMed reviewer concluded that for the Plaintiff, “[t]he continued use of IVIG is not medically necessary,” and that IVIG is not effective as maintenance therapy for patients with chronic MG. (Doc. 22, at 11; Doc. 23, Ex. A, at 135). The AllMed reviewer further provided:

[T]he documentation suggests that IVIG is being used as maintenance therapy for chronic myasthenia in this case. There is no evidence in the peer-reviewed medical literature that IVIG maintenance therapy for myasthenia gravis provides long-term benefit with regard to clinical outcomes.
While IVIG has been shown to be effective in acute myasthenia gravis exacer-bations, there is no evidence that the use of IVIG is superior to corticosteroids in the treatment of exacerbations. This member is not documented to be refractory to the use of corticosteroids, and IVIG has not been shown to be effective as maintenance therapy. Since there is no evidence of this member experiencing a medically acute myasthenia exacerbation, the ongoing use of IVIG is not medically necessary per the policy.

(Id).

Plaintiff discounts that the AllMed reviewer fully considered the notes of Plaintiffs office visits or medical testing, because Plaintiffs neurologist, Dr. Freid-enberg, reported that Plaintiff:

“[H]as been undergoing treatment for Myasthenia Gravis since December of 2007”;
That “since that time, [Plaintiff] has failed [is refractory to] Cellcept, Cyclos-porine, and Tacrolimus. Cyclosporine results in renal dysfunction. Cellcept did not produce desired results. Tacrolimus caused extreme lethargy and mental clouding”;
That “chronic steroid use has resulted in Serous Retinopathy as noted by Joseph Shovlin, OD of Northeastern Eye Institute”; and
Doctors Freidenberg and Shovlin “attempted tapering [Plaintiffs] IVIG in the past; however, have been unsuccessful as a flare of symptoms always recurs.”

(Doc. 26, at 11; Doc. 23, Ex. A, at 176).

On September 20, 2013, Defendant notified Plaintiff that it denied her request for biweekly IVIG treatment, stating that:

Upon review of the information received, there is no evidence in the peer-reviewed literature that IVIG maintenance therapy for the diagnosis of myasthenia gravis provides long term benefit with regard to clinical outcomes. Therefore, this request is denied.

(Doc. 22, at 12; Doc. 26, 12; Doc. 23, Def.’s Ex. A, at 139-140). Plaintiff sought expedited review of this denial. (Id. at 13). Defendant’s Internal Review Committee [468]*468considered the appeal on October 24, 2013, and determined that the denial of IVIG treatment for Plaintiff was proper, explaining:

There is no evidence of acute myasthenic crisis. There is no evidence of postoperative or planned thymectomy. There is no documentation of failure or intolerance to three months of two standard treatments. The policy coverage criteria for IVIG for myasthenia gravis are not met.
A 2008 Cochrane article identified six randomized controlled trials of IVIG for myasthenia gravis. The report concluded: “In chronic myasthenia gravis, there is insufficient evidence from randomized trials to determine whether IVIG is efficacious.”
Per the American Association of Neuro-muscular & Electrodiagnostic medicine guidelines: “Insufficient data exist on the role of IVIG in the chronic management of myasthenia gravis.”
Myasthenic crisis is a life-threatening condition, which is defined as weakness from acquired myasthenia gravis that is severe enough to necessitate intubation or to delay extubation following surgery. There is no evidence that the patient is currently experiencing myasthenic crisis. IVIG can be considered for myasth-enic crisis but its efficacy for chronic myasthenia gravis is unproven.
The policy is consistent with the current medical literature. There are no clinical circumstances unique to this case which would support a policy override, and as such, the request is not medically necessary in accordance with generally accepted standards of medical practice.

(Doc.

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Bluebook (online)
196 F. Supp. 3d 463, 2016 WL 3940714, 2016 U.S. Dist. LEXIS 95195, Counsel Stack Legal Research, https://law.counselstack.com/opinion/clauss-v-plan-pamd-2016.