Rahn v. Montana Rail Link Benefit Plan

CourtDistrict Court, D. Montana
DecidedSeptember 28, 2020
Docket9:19-cv-00141
StatusUnknown

This text of Rahn v. Montana Rail Link Benefit Plan (Rahn v. Montana Rail Link Benefit Plan) is published on Counsel Stack Legal Research, covering District Court, D. Montana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Rahn v. Montana Rail Link Benefit Plan, (D. Mont. 2020).

Opinion

FILED □

IN THE UNITED STATES DISTRICT COURT 09/28/2020 FOR THE DISTRICT OF MONTANA OSE Us □□ MISSOULA DIVISION Great Fas Division

WENDY RAHN, Plaintiff, CV 19-141-M-JTJ

VS. MEMORANDUM MONTANA RAIL LINK BENEFIT AND ORDER PLAN, WASHINGTON CORPORATIONS, and JOHN DOES 1-5, Defendants.

INTRODUCTION Plaintiff Wendy Rahn (Rahn) brings this action under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §1132(a)(1)(B). Rahn seeks a declaration that she was wrongfully denied medical benefits under an employer-sponsored health benefits plan administered by Defendant Washington Corporations (Washington Corp.). The parties have filed cross-motions for

summary judgment. The Court conducted a hearing on the motions on August 27, 2020. The Court is prepared to rule. BACKGROUND Rahn is a woman in her early forties. Rahn suffers from a significant and worsening degenerative condition in her cervical spine. Rahn’s husband works for

Montana Rail Link. Montana Rail Link funds a health benefit plan known as the Montana Rail Link Medical Benefit Plan (Plan). The Plan is regulated by ERISA. Rahn participates in the Plan as an eligible dependent of a Montana Rail Link employee. Defendant Washington Corp. is the Plan Administrator. Washington Corp. possesses the authority to review and make final decisions on all claims for benefits made by Plan participants. Allegiance Benefit Plan Management Inc. (Allegiance) is the Plan Supervisor. Allegiance reviews claims made by Plan participants and makes claims recommendations to Washington Corp. Rahn began receiving physical therapy for pain in her right shoulder and neck on September 14, 2015, at Big Sky Physical Therapy in Missoula, Montana. (Doc. 16-1 at 268). Licensed physical therapist Dawn Christian (Christian) provided the physical therapy. (Doc. 16-1 at 270). Christian provided physical therapy treatments to Rahn for several years. Rahn had her 33rd physical therapy treatment for cervical brachial pain on January 18, 2018. (Doc. 16-1 at 297). The

treatment diagnosis on that date was “pain in right shoulder, pain in right upper arm, low back pain, pain in right wrist, pain in right hand and pain in left hand.” Td.

-2-

Neurosurgeon Dr. Chriss Mack evaluated Rahn on September 5, 2017, regarding her persistent issues with cervical brachial pain in her upper back and neck. (Doc. 16-1 at 196). An MRI revealed degenerative disc disease at C3-4, 5- 6, and 6-7, and a significant bilateral C6 nerve root compression. (Doc. 16-1 at 199). Dr. Mack determined that fusion surgery was not a good option given Rahn’s relatively young age. Jd. Dr. Mack referred Rahn to the Providence Medical Group Spine and Pain Center. (Doc. 16-1 at 200). Dr. Christopher Caldwell of the Providence Medical Group Spine and Pain Center evaluated Rahn in response to Dr. Mack’s referral. (Doc. 16-1 at 378). Dr. Caldwell administered steroid injections which did not relieve Rahn’s symptoms. Dr. Caldwell diagnosed Rahn with “[c]hronic right-sided low back pain with right- sided sciatica” [and] right hip pain.” (Doc. 16-1 at 379). Dr. Caldwell referred Rahn to Christian for physical therapy on her lower back in early February 2018. (Doc. 16 at 5-6). Dr. Caldwell instructed Christian

to address: “posture, muscle imbalance, core stabilization as indicated, and

progress to independent home exercise program with minimal use of modalities.” (Doc. 16-1 at 379). Rahn had her first physical therapy visit for her lower back pain on February 26, 2018. (Doc. 16-1 at 364). Christian diagnosed Rahn with right-sided

-3-

lumbago with sciatica, right hip pain, and other chronic pain. Jd. Christian developed a 12 week physical therapy plan that included therapeutic exercises, therapeutic activity, neuromuscular rehabilitation, and manual therapy. (Doc. 16-1 at 365). Both Dr. Caldwell and Christian certified that the treatment plan was medically necessary. Jd. Rahn received 3 physical therapy treatments for her lower back during the time period from February 26, 2018, through April 26, 2018. (Doc. 16-1 at 71). The Plan provides coverage for physical therapy so long as the physical therapy is ordered by a physician, rendered by a licensed physical therapist, and

meets the Plan’s definition of “medically necessary.” (Doc. 16-2 at 23, 93). The Plan defines the terms “medically necessary” and “medical necessity” as “treatment[s], tests, services or supplies” that meet all of the following criteria: 1. [They] are to treat or diagnose an I!lness or Injury; and 2. [They] are ordered by a Physician or Licensed Health Care Provider and consistent with the symptoms or diagnosis and treatment of the Illness or Injury; and 3. [They] are not primarily for the convenience of the Covered Person, Physician or other Licensed Health Care Provider; and 4. [They] are the standard or level of services most appropriate for good medical practice that can be safely

-4.

provided to the Covered Person and are in accordance with the Plan’s Medical Policy; and 5. [They] are not of an Experimental/Investigational or solely educational nature; and 6. [They] are not provided primarily for medical or other research; and 7. [They] do not involve excessive, unnecessary or repeated tests; and 8. [They] are commonly and customarily recognized by the medical profession as appropriate in the diagnosis or treatment of the diagnosed condition; and 9. [They] are approved procedures or meet required guidelines or protocols of the Food and Drug Administration (FDA) or Centers For Medicare/Medicaid Services (CMS), pursuant to that entity’s program oversight authority based upon the medical treatment circumstances. (Doc. 16-2 at 93-94). On April 10, 2018, Allegiance questioned whether the physical therapy prescribed by Dr. Caldwell was medically necessary. Allegiance sought an independent medical review. Allegiance hired Dr. Akhil Chhatre of the Medical Review Institute of America, LLC, to conduct the external review. Dr. Chhatre issued his report on April 13, 2018. (Doc. 16-1 at 207-209). Dr. Chhatre concluded that the physical therapy that Dr. Caldwell had prescribed

-5-

for Rahn in February 2018 was not medically necessary. (Doc. 16-1 at 207). Dr. Chhatre stated that the physical therapy was not medically necessary because Rahn had received physical therapy for right shoulder pain in the past, she “ha[d] not demonstrated progress in the physical therapy already administered,” and she “continue[d] to complain of the same pain despite attending physical therapy.” (Doc. 16-1 at 207-08). Unfortunately, Dr. Chhare did not recognize that the physical therapy that Dr. Caldwell had prescribed in February 2018 was for Rahn’s lower back, not her right shoulder. Washington Corp. adopted Dr. Chhare’s findings. Washington Corp. informed Rahn that the Plan did not cover the physical therapy prescribed by Dr. Caldwell because the therapy was not medically necessary. (Doc. 16-1 at 210). Rahn appealed the Plan’s decision on May 4, 2018. The appeal documents that Rahn submitted included a letter from Christian dated April 26, 2018. (Doc. 16-1 at 71). Christian explained in her letter that the physical therapy that Dr. Caldwell had prescribed in February 2018 was for Rahn’s lower back, not her neck and shoulders. Jd. Christian stated: “Wendy Rahn has received physical therapy treatment at Big Sky Physical therapy for her right thumb, right elbow, neck, and low back. She was initially evaluated for her right thumb on 9/14/15 post surgery. With the evaluation I found her symptoms were related to her

-6-

right elbow, shoulder, and neck.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
Rahn v. Montana Rail Link Benefit Plan, Counsel Stack Legal Research, https://law.counselstack.com/opinion/rahn-v-montana-rail-link-benefit-plan-mtd-2020.