UBH Found to Have Wrongfully Denied Care Using Flawed Medical Necessity Criteria

The United States District Court for the Northern District of California this week found that United Behavioral Health (UBH/Optum), the country’s largest managed behavioral health care organization, illegally denied mental health and substance use coverage based on flawed medical necessity criteria.

In the case, David Witt, et. al. v. United Behavioral Health, Chief Magistrate Judge Joseph C. Spero said that UBH used internally developed medical necessity guidelines that comprehensively fell short of accepted standards of care to deny outpatient, intensive outpatient, and residential treatment to UBH beneficiaries. Plaintiffs were individuals insured by UBH.

The court looked to clinical guidelines from APA, the American Society of Addiction Medicine, other professional associations, and the Centers for Medicare and Medicaid Services to establish the applicable standards of care. Judge Spero outlined specific aspects of coverage that the accepted standards call for but that UBH did not meet. They include the following:

• Effective treatment requires treatment of the individual’s underlying condition and is not limited to alleviation of the individual’s current symptoms.
• Effective treatment requires treatment of co-occurring behavioral health disorders and/or medical conditions in a coordinated manner that considers the interactions of the disorders and conditions and their implications for determining the appropriate level of care.
• Patients should receive treatment for mental health and substance use disorders at the least intensive and restrictive level of care that is safe and effective – the fact that a lower level of care is less restrictive or intensive does not justify selecting that level if it is also expected to be less effective. Placement in a less restrictive environment is appropriate only if it is likely to be safe and just as effective as treatment at a higher level of care in addressing a patient’s overall condition, including underlying and co-occurring conditions.
• When there is ambiguity as to the appropriate level of care, the practitioner should err on the side of caution by placing the patient in a higher level of care.
• Effective treatment of mental health and substance use disorders includes services needed to maintain functioning or prevent deterioration.
• Appropriate duration of treatment for behavioral health disorders is based on the individual needs of the patient; there is no specific limit on the duration of such treatment.
• The unique needs of children and adolescents must be taken into account when making level of care decisions involving their treatment for mental health or substance use disorders.
• The determination of the appropriate level of care for patients with mental health and/or substance use disorders should be made on the basis of a multidimensional assessment that takes into account a wide variety of information about the patient.

“Having reviewed all of the versions of the Guidelines that Plaintiffs challenge in this case and considered the testimony of the witnesses addressing the meaning of the Guidelines, the Court finds, by a preponderance of the evidence, that in every version of the Guidelines in the class period, and at every level of care that is at issue in this case, there is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions,” Spero wrote. “[I]n each version of the Guidelines at issue in this case the defect is pervasive and results in a significantly narrower scope of coverage than is consistent with generally accepted standards of care.”

This case is significant for patients and health care professionals who have long advocated for the use of medical necessity guidelines developed by professional organizations rather than those created by the insurance industry. While the case did not directly involve the federal parity law, the court recognized that mental and substance use disorders are chronic illnesses and rejected the insurer's practice of treating patients only for acute symptoms. This establishes a precedent for plans covered by the parity law requiring that they pay for continued treatment for mental and substance use disorders as they would for any other chronic illness.

For related information, see the Psychiatric News article “Assembly Seeks Help forMembers Appealing Insurance Denials.”

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