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Employee Retirement Income Security Act (ERISA) › Medical Necessity

Ogletree, Deakins, Nash, Smoak & Stewart,...

Ninth Circuit Affirms ERISA Plan Administrator’s Decision, Validates Use of Industry Guidelines and Medical Evidence

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On March 5, 2019, Magistrate Judge Joseph C. Spero of the U.S. District Court for the Northern District of California issued his opinion in Wit v. United Behavioral Health, in which he attempted to significantly change how...more

Sheppard Mullin Richter & Hampton LLP

Less is More: Brevity is the Soul of Wit

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Last month, a three-judge panel in the Ninth Circuit reversed the Northern District of California’s ruling in Wit v. United Behavioral Health. In Wit, the district court ruled that United Behavioral Health (“UBH”) breached...more

Hinshaw & Culbertson LLP

Denial of Mental Health Treatment Benefits Ruled Improper under Milliman Care Guidelines

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In Jessica U. v. Health Care Service Corp., a Montana district court held that an ERISA plan administrator improperly denied benefits for mental health residential treatment based solely on so-called "Milliman Care...more

Hinshaw & Culbertson LLP

The LHD/ERISA Advisor - October 2020: Tenth Circuit Finds District Court Applied Wrong Standard of Review in Evaluating Plan...

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In Lyn M. v. Premera Blue Cross, 2020 U.S. App. LEXIS 23395 (10th Cir. July 24, 2020), the Tenth Circuit held that a district court had applied the wrong standard of review and incorrectly evaluated an ERISA plan...more

Littler

“Medical Necessity” Isn’t Well-Defined Unless It Is Well-Defined

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A U.S. District Court in Connecticut recently issued an order that highlights the importance of understanding exactly what the term “medically necessary” means in an ERISA health plan....more

Ogletree, Deakins, Nash, Smoak & Stewart,...

District Court in California Denies Motion to Dismiss, Finds an Independent Review Organization to Be a Functional Fiduciary Under...

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In Josef K. v. California Physicians’ Service, No. 18-cv-06385-YGR (U.S. District Court for the Northern District of California, June 3, 2019), Judge Yvonne Gonzalez Rogers concluded that an independent medical review (IMR)...more

Seyfarth Shaw LLP

Fourth Circuit Affirms Health Care Fraud Convictions for Billing Insurers for Medically Unnecessary Services

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Seyfarth Synopsis: The Fourth Circuit found that the medical necessity of a given service constitutes a material element of representations regarding submissions for payment, potentially providing payors with another legal...more

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