Opinion
CASE NO. 20-80545-CIV-MARRA
2022-01-27
Sharon PROLOW and Mark Lemmerman, on behalf of themselves and all others similarly situated, Plaintiffs, v. AETNA LIFE INSURANCE COMPANY, Defendant.
Frank Anthony Florio, Maria Dolores Garcia, Kozyak Tropin & Throckmorton LLP, Miami, FL, Harley Shepard Tropin, Robert J. Neary, Kozyak Tropin & Throckmorton, P.A., Stephanie Anne Casey, Colson Hicks Eidson, Coral Gables, FL, for Plaintiff Sharon Prolow. Robert J. Neary, Kozyak Tropin & Throckmorton, P.A., Stephanie Anne Casey, Colson Hicks Eidson, Coral Gables, FL, for Plaintiff Mark Lemmerman. Ardith M. Bronson, Maia Sevilla-Sharon, DLA Piper LLP, Miami, FL, Brian H. Benjet, Pro Hac Vice, DLA Piper LLP, Philadelphia, PA, Jon W. Breyfogle, Pro Hac Vice, Mark C. Nielsen, Pro Hac Vice, Paul J. Rinefierd, Pro Hac Vice, Groom Law Group Chartered, Washington, DC, for Defendant.
Frank Anthony Florio, Maria Dolores Garcia, Kozyak Tropin & Throckmorton LLP, Miami, FL, Harley Shepard Tropin, Robert J. Neary, Kozyak Tropin & Throckmorton, P.A., Stephanie Anne Casey, Colson Hicks Eidson, Coral Gables, FL, for Plaintiff Sharon Prolow.
Robert J. Neary, Kozyak Tropin & Throckmorton, P.A., Stephanie Anne Casey, Colson Hicks Eidson, Coral Gables, FL, for Plaintiff Mark Lemmerman.
Ardith M. Bronson, Maia Sevilla-Sharon, DLA Piper LLP, Miami, FL, Brian H. Benjet, Pro Hac Vice, DLA Piper LLP, Philadelphia, PA, Jon W. Breyfogle, Pro Hac Vice, Mark C. Nielsen, Pro Hac Vice, Paul J. Rinefierd, Pro Hac Vice, Groom Law Group Chartered, Washington, DC, for Defendant.
ORDER ON-CROSS MOTIONS FOR SUMMARY JUDGMENT
KENNETH A. MARRA, United States District Judge
Plaintiffs bring this putative class action under the Employee Retirement Income Security Act of 1974 ("ERISA") 29 U.S.C. § 1001, et seq. against Defendant Aetna Life Insurance Company ("Aetna") alleging they were wrongfully denied coverage for Proton Beam Radiation Therapy ("PBRT") under employee welfare benefit plans issued by their employers and administered by Aetna. Plaintiffs bring the action on behalf of themselves and all putative class members who have been denied coverage for the same type of medical treatment under plans administrated by Aetna.
The case is before the Court on Plaintiffs’ Motion for Partial Summary Judgment [DE 110] seeking to establish (1) the applicability of a de novo standard of review to Aetna's denial of Plaintiffs’ substantive claims and an adjudication that Aetna's decision on PBRT coverage was wrong on both claims, in violation of Plan terms, and therefore must be reversed; (2) alternatively, assuming applicability of an abuse of discretion standard, an adjudication that Aetna's decision on PBRT coverage was unreasonable (arbitrary and capricious) on both claims and therefore must be reversed; (3) the applicability of a de novo standard of review to the adequacy of Aetna's claims handling procedures and an adjudication that Aetna failed to afford a full and fair review of Plaintiffs’ claims for PBRT coverage in conformity with ERISA procedural requirements, and instead categorically applied an Aetna policy bulletin to deny the claims.
Defendant Aetna has also moved for summary judgment seeking a determination that an arbitrary and capricious standard applies to the Court's review of Plaintiffs’ claims, and an adjudication that Aetna's decision to deny PBRT coverage was a reasonable one based on its discretionary interpretation of plan coverages and evidence in the administrative record [DE 112]. Both motions are now ripe for review. Having carefully considered the parties’ written submissions and the administrative record, the Court grants Plaintiffs’ Motion for Summary Judgment and denies Defendant's Motion for Summary Judgment.
In response to Plaintiffs’ Motion, Aetna filed a Response in Opposition [DE 122] and Responses to Plaintiffs’ Statement of Undisputed Facts [DE 123]. Plaintiff filed a Reply in Support [DE 129] and a Reply to Defendant's Additional Facts [DE 130]. In support of its Motion, Aetna filed a separate Statement of Undisputed Facts [DE 113]. In response to Aetna's motion, Plaintiffs filed a Response in Opposition and a Response to Defendants’ Statement of Undisputed Facts [DE 120, 121]. Aetna filed a Reply in Support and a Reply Statement of Facts [DE 131, 132].
The Court has determined the facts based on the parties’ submissions, including the administrative record, which are undisputed unless otherwise noted. Under Local Rule 56, "[a]ll material facts set forth in the movant's statement" of material facts "will be deemed admitted unless controverted by the opposing party's statement, provided that the Court finds that the movant's statement is supported by evidence in the record." L.R. 56.1(b).
References to the Administrative Record compiled by Aetna for Sharon Prolow and Mark Lemmerman are designated in this Order by the word "AETNA" followed by the stamped Bates page number that appears in the bottom right corner of each page of that record.
This action seeks reversal of Aetna's decisions, as the Claims Administrator for employee welfare benefit plans issued by Plaintiffs’ respective employers, to deny benefits eligibility for PBRT to treat Plaintiffs’ cancers.
A. Plaintiffs and the Plans
Ms. Prolow is a participant in a self-funded employee welfare benefit plan established by her employer, AllianceBernstein, LLC ("Alliance Plan") which is governed by ERISA. The terms of the Plan are written in a Plan Booklet, which describes coverages extended by the Plan, and a Schedule of Benefits, which describes how expenses are shared and identifies the limits of coverage (AETNA 446-554). Mark Lemmerman is a participant in a self-funded employee welfare benefit health plan established by his employer, Covanta Projects LLC ("Covanta Plan"), which also is governed by ERISA. The terms of the Covanta Plan are likewise written in a Plan Booklet and Schedule of Benefits (AETNA 1245-1344).
Both Plans designate Aetna as a third-party administrator. Both employers entered into administrative service agreements called "Master Service Agreements" ("MSAs") with Aetna, documents which include the following clause:
[T]o the extent not already implied as a matter of law, Customer hereby delegates to Aetna discretionary authority to determine entitlement to benefits under the applicable Plan documents for each claim received including discretionary authority to determine and evaluate facts and evidence, and discretionary authority to construe the terms of the Plan. It is also agreed that, between Customer and Aetna, Aetna's decision on any claim is final and Aetna has no other fiduciary responsibility.
(AETNA 1735, 1803).
Relying on language found in the MSAs and Plan Booklets, Aetna urges application of a deferential standard of review, positing as follows: (1) the MSAs for both employers contain language designating Aetna as the "appropriate named fiduciary" of each Plan "for the purpose of reviewing denied claims under the Plan(s)," and expressly vest it with discretionary authority sufficient under Firestone to trigger deferential review; (2) the language of the MSAs is "consistent with the terms of the Plan Booklets," terms it contends "further evidence discretionary authority that the Plan sponsors delegated to Aetna." Here, Aetna points to language found in both Plan Booklets providing that a member is entitled to seek external review if "[w]e (defined to mean Aetna) decided the service or procedure is not medically necessary or not appropriate" or "[w]e (Aetna) decided the service or supply is experimental or investigational." In addition, it references language in the Booklets reciting that "we" (Aetna) define "medical necessity" in the Glossary, where "our" (Aetna's) medical directors or their physician designees explain what is considered in determining if an eligible health service is medically necessary.
Aetna argues that the plan documents are properly deemed to include the MSAs for purposes of determining the appropriate standard of review (i.e., for deciding whether discretionary decision-making authority was conferred), citing to a number of district court cases where courts have deemed an administrative service agreement to be a component of the "plan document" for purposes of evaluating the vesting of discretionary decision-making authority [Aetna Initial Brief at 12-13]. The Court disagrees that the MSAs at issue in this case are properly deemed part of the "Plan Documents" governing the Alliance or Covanta Plans for purposes of making this assessment, as more particularly discussed in the Standard of Review discussion, infra.
Finally, Aetna contends the Covanta Plan is also governed by a "Wrap Plan" which expressly delegates authority for benefits eligibility decision-making as follows:
The administration of the Plan is under the supervision of the company [Covanta] as Plan Administrator ... The principal duty of the Plan Administrator is to see that the plan is carried out, in accordance with its terms, for the exclusive benefit of persons entitled to participate in the Plan. The administrative duties of the Plan Administrator include, but are not limited to, interpreting the Plan, prescribing applicable procedures, determining eligibility for and the number of benefits, authorizing benefit payments and gathering information necessary for administering the Plan. The Plan Administrator may delegate any of these administrative duties among one or more persons or entities, provided such delegation is in writing, expressly identifies the delegate(s) and expressly describes the nature and scope of the delegated responsibility.
Plaintiffs dispute that the MSAs are properly viewed as components of the "plan documents" comprising the Alliance or Covanta Plans; they dispute that the Plan Booklets confer discretionary decision-making authority on Aetna; they dispute whether the Covanta "Wrap Plan" was in effect at the time Aetna processed Mr. Lemmerman's claim; and they dispute whether the Covanta "Wrap Plan" in any event effectively confers discretionary decision-making authority on Aetna.
1. Medical Necessity
The Alliance Plan and Covanta Plan each recite that there are two documents "that together describe the benefits covered by your Employer's self-funded health benefit plan." (AETNA 449, 1247). One document is the Plan Booklet, which "will tell you about your covered benefits - what they are and how you can get them," and the other is the Schedule of Benefits, which "tells you how we share expenses for eligible health services and tells you about limits – like when your plan covers only a certain number of visits." (AETNA 454, 1251).
The Plan Booklets describe "covered benefits" to include "medically necessary" health care services, and both define "medically necessary" to mean:
Health care services that a provider exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:
? In accordance with generally accepted standards of medical practice
? Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease
? Not primarily for the convenience of the patient, physician, or other health care provider
? Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease
(AETNA 460, 1256).
In turn, the Plans define "generally accepted standards of medical practice" to mean:
? Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community.
? Consistent with the standards set forth in policy issues involving clinical judgment.
(AETNA 539, 1329).
2. Experimental or Investigational Treatment Exclusion
Both Plans exclude "experimental or investigational" treatments or procedures from coverage (AETNA 492-494; 1287–1289) and both define "Experimental or Investigational" to mean:
A drug, device, procedure, or treatment that is found to be experimental or investigational because:
? There is not enough outcome data available from controlled clinical trials published in the peer-reviewed literature to validate its safety and effectiveness for the illness or injury involved
? The needed approval by the FDA has not been given for marketing
? A national medical or dental society or regulatory agency has stated in writing that it is experimental or investigational or suitable mainly for research purposes
? It is the subject of a Phase I, Phase II or the experimental or research arm of a Phase III clinical trial. These terms have the meanings given by regulations and other official actions and publications of the FDA and Department of Health and Human Services
? Written protocols or a written consent form used by a facility provider state that it is experimental or investigational
(AETNA 537, 1327).
3. PBRT and Aetna's Clinical Policy Bulletin No. 270
PBRT is a procedure that deposits protons over a very small area, allowing a precise targeting of high doses of proton beams to a tumor, with no "exit dose" beyond the tumor involved (AETNA 274, 1027, 1461). It enables patients to tolerate higher total doses of radiotherapy, compared with photons, which are used for traditional intensity-modulated radiation therapy ("IMRT"). Id. It is viewed as particularly useful in treating tumors near vital organs or structures, where surgical excision or administration of adequate doses of conventional radiation is difficult or impossible (AETNA 339). It is also associated with reduced risk of ischemic heart disease, including fatal heart attacks (AETNA 277). On February 22, 1988, the United States Food and Drug Administration ("FDA") approved the Proton Therapy System ("PTS"), which it describes as a "device that produces by acceleration high energy charged particles (e.g., electrons and protons) intended for use in radiation therapy." 21 C.F.R. § 892.5050. The FDA has issued the following statement of indications for intended use: "The [Proton Therapy System] is a medical device designed to produce and deliver proton beams for the treatment of patients with localized tumors and other conditions susceptible to treatment by radiation." (AETNA 273).
Aetna has developed internal clinical policy bulletins that explain its policies on certain medical services and guide its coverage decisions under various health insurance plans administered by it [Aetna's Initial SJ Brief, DE 115 at 4]. As relevant to this case, Aetna created a Clinical Policy Bulletin for PBRT, entitled "Proton Beam, Neutron Beam and Carbon Ion Radiotherapy" ("CPB No. 270"), which it revises and updates from time to time. The CPB No. 270 in effect at the time Aetna processed Ms. Prolow's claim (reciting a last review date May 19, 2018, eff. date July 16, 1998, and next review date March 14, 2019) states that Aetna considers PBRT to be "medically necessary" in the treatment of any "radiosensitive tumors" involving "malignancies in children (21 years of age and younger)" (in addition to certain brain, spine and eye sarcomas or melanomas for persons of any age) (Section I); that Aetna considers PBRT "not medically necessary for individuals with localized prostate cancer because it has not been proven to be more effective than other radiotherapy modalities for this indication;" (Section II) and that it considers PBRT "experimental and investigational for all other indications," including breast cancer in adults, "because its effectiveness for [this] indication[ ] has not been established." (Section III) (AETNA 334-335) (AETNA 129-130).
The parties dispute the purpose of the revisions to CPB NO. 270, with Aetna claiming the revisions are intended "to account for scientific and medical development in the field." On the other hand, Plaintiffs contend there is no evidence in the record illuminating the reasons for the revisions. Plaintiffs argue that the version of CPB No. 270 in place when their claims were processed ignores relevant scientific and medical developments in the field, is based on outdated medical evidence, and was categorically applied by Aetna to produce arbitrary, unreasonable interpretations of Plan coverages inconsistent with Plan terms.
The version of CPB No. 270 in effect between July 2019 and October 2020, when Aetna processed Mr. Lemmerman's claim, also stated that Aetna "considers [PBRT] for treatment of prostate cancer not medically necessary for individuals with localized prostate cancer because it has not been proven to be more effective than other radiotherapy modalities for this indication." (AETNA 1112-1235 at AETNA 1112). At the same time, in an internal document entitled, "Job Aid: Medical Director Reviews," created for the stated "purpose" of "Provid[ing] consistent handling for precertification/concurrent reviews that require review by a Medical Director," Aetna instructs that approval for PBRT coverage should be given if "proton beam therapy is requested for treatment of prostate cancer at The Maryland Proton Treatment Center ... based on an agreement with this facility" (effective/implementation date - 8/19/2013; revision date - 10/26/2020) (AETNA 8006 – 8015; AETNA at 8011) [DE 109-5 at 7].
In contrast, the current version of CPB No. 270 provides: "Aetna considers proton beam radiotherapy and IMRT clinically equivalent for localized cancer of an intact prostate. Medical necessity will be determined based on the terms of the member's benefit plan. Please check benefit plan descriptions." Plaintiffs’ Statement of Facts [DE 109-2, ¶ 17] (citing http://www.aetna.com/cpb/medical/data/200_299/0270.html#dummyLink4 ).
B. Sharon Prolow: Diagnosis, Treatment and Denial of Claim
Ms. Prolow was diagnosed with breast cancer in October 2017. She underwent a double mastectomy in November 2017 and remained cancer free until August 2018 when she suffered a recurrence of her cancer. She underwent surgery for removal of her recurrent tumor in August 2018, followed by six cycles of chemotherapy administrated in late 2018 through January 2019. At that point, her team of oncologist specialists at Miami's Cancer Institute at Baptist Health South Florida recommended that she undergo PBRT, a newer and more targeted radiation-based cancer treatment, as opposed to intensity modulated radiotherapy ("IMRT"), a traditional and typically less expensive radiation-based cancer treatment. The recommendation was based on the lower risk of radiation-based sided effects associated with proton therapy as well as cardiac risk factors. Her physician found the latter particularly relevant in Ms. Prolow's case due to "a family history of cardiac disease with prior exposure to systemic therapy potentially placing [the patient] at increased risk of treatment-induced cardiac toxicity which could be exacerbated by undesired radiation exposure of the heart." (AETNA 284). Dr. Marcio Fagundes, Ms. Prolow's radiation oncologist, submitted a preauthorization request for PBRT to Aetna on her behalf on March 4, 2019.
On March 6, 2019, Aetna denied the request, in a decision letter signed by Dr. Carl Salina, Medical Director, on the expressed rationale: "Based on the CPB criteria and the information we have, we are denying coverage for proton beam radiotherapy. Clinical studies have not proven that the procedure is effective for treatment of the member's condition ... (Experimental/Investigatory Denial) This coverage denial was based on the terms of the member's benefit plan document ... The plan does not cover experimental or investigational services except under certain conditions. Please see the reference to experimental or investigational services listed in the Exclusions section of the benefit plan documents." (AETNA 047).
Dr. Fagundes submitted a first-level appeal to Aetna on March 14, 2019, explaining in pertinent part:
[T]he patient would have significant benefit from proton therapy with a marked reduction in the dose delivered to the heart (more than 10-fold reduction) with a mean heart dose that is reduced from 7.1 Gy with IMRT down to 0.1 Gy with protons. Doses above 6 Gy have justified utilizing alternative modalities to lower the heart exposure. .....
This patient is a perfect example of a very complex scenario where comprehensive nodal irradiation including internal mammary lymph nodes is needed and this would result in significant cardiac exposure if the patient is treated with intensity modulated radiotherapy ....
It is worth remembering that the National Comprehensive Cancer Network's (NCCN) 2015 Guidelines provide that: CT-based treatment planning is encouraged to identify lung and heart volumes and minimize exposure of these organs." PBT is ideal and recommended to meet the NCCN guideline to minimize radiation exposure to the lung and heart. .... This is corroborated by ASTRO'S recommendation to maximize efforts to reduce cardiac exposure whenever possible without compromising target dose coverage. ..... The risk of radiation-induced heart disease is well known in the medical literature and this patient's IMRT showed an excessive >8 Gy mean heart dose. Proton therapy should be considered as medically necessary in this patient as the best suited modality to achieve dose delivery with real potential for cure while avoiding risks of serious acute and permanent treatment-induced complications....
Proton therapy is not experimental : The DHHS/FDA approved proton therapy on Feb 22, 1988 with the following specific statement indications for intended use: Device Name: Proton Therapy System ... "The PTS is a medical device designed to produce and deliver a proton beam for the treatment of patients with localized tumors and other conditions susceptible to treatment by radiation...." Please note that this patient meets every criterion as defined by
the FDA for appropriateness of use and therefore designating this as experimental is fallacious, inaccurate, and contrary to the public record.
(AETNA 110-112) (AETNA 251-252).
Dr. Fagundes appended data on PBRT efficacy in breast cancer cases, including peer-reviewed papers published in the New England Journal of Medicine, the Journal of Oncology, and International Journal of Radiation Oncology (AETNA 273-279), along with PET scans, CT scans and images showing the location of Ms. Prolow's recurrent tumor and the risk to vital organs (lungs and heart) posed by IMRT in her specific situation (AETNA 281). He opined that PBRT for Ms. Prolow could "easily achieve" a "marked reduction in the dose [of radiation] delivered to the heart (more than 10-fold reduction)" noting that "doses above 5 Gy have justified utilizing alternative modalities to lower the heart exposure ... [T]he key factor here is that the heart dose [with IMRT] is still higher than acceptable levels, irrespective of the side of the cancer ..." (AETNA 280). Dr. Fagundes also noted that the patient would be enrolled in a "multi-institutional registry outcomes clinical trial through the Proton Collaborative Group" (AETNA 281).
Aetna referred the appeal to a third-party vendor, "Medical Review Institute of America LLC" ("MRIoA"), for a recommendation. It forwarded three documents to MRIoA -- Dr. Fagundes letter, Aetna's initial denial letter and a copy of CPB No. 270 -- and directed the reviewer to "Please use Clinical Policy Bulletin Proton Beam and Neutron Beam Radiotherapy (0270), review date May 9, 2018" (AETNA 226-227). On March 20, 2019, the assigned medical reviewer at MRIoA, Dr. Gregg Goldin, recommended that Aetna uphold its denial stating:
The requested Proton Beam Therapy is considered experimental/investigational (and therefore not medically necessary) for this member based on the submitted information, current peer-reviewed literature, reviewer experience, and Aetna CPB #0270 for Proton Beam and Neutron Beam Radiotherapy. Although proton radiation is FDA approved for management of malignancy in general, there is insufficient high quality clinical outcomes reported in the peer reviewed medical literature to allow one to make definitive conclusions about the relative safety/efficacy of proton radiation in the member's setting, as compared to standard of care photon radiation. The provider has not performed a comparison utilizing an electronic patch technique which may enable improved coverage of the internal mammary nodal chain while further minimizing exposure to the patient's heart. Proton radiation is not supported by the Modal Policy for Proton radiation in the member's setting outside the context of a clinial trial.
(AETNA 229-300).
On March 21, 2019, Aetna sent a letter to Dr. Fagundes notifying him of its decision to uphold its denial of the request for precertification. It did not reference the content of the MRIoA report, but simply explained its decision by citing CPB 270, quoting the text of the E/I exclusion, and concluding: "Based on our review of the information given and Aetna's Clinical Policy Bulletin (CPB) Proton Beam and Neutron Beam Radiotherapy (270) review date May 09, 2018 used for case review, we are upholding the prior denial of coverage. The basis of this determination is that the member did not meet the criteria. As per the CPB noted above, Aetna considers proton beam radiation experimental and investigational for the treatment of breast cancer, as the effectiveness in this condition has not been established. Therefore, criteria are not met, and the previous denial of coverage is upheld." (AETNA 237). On March 26, 2019, Dr. Fagundes submitted a second-level appeal to Aetna (AETNA 250-268). Four hours later, Aetna issued a letter denying the appeal, again citing CPB No. 270 and the text of the "experimental or investigational" definition found in the Alliance Summary Plan Description, stating "This is a 50-year-old female with recurrent breast cancer. Aetna considers proton beam radiotherapy experimental and investigational for breast cancer. This decision was made utilizing the Aetna CPB referenced above." (AETNA 291).
On March 28, 2019, Dr. Fagundes requested an external appeal of Aetna's decision, which Aetna submitted to a third-party vendor called Medical Care Management Corporation ("MCMC"). On April 1, 2019, MCMC upheld the denial of benefits, issuing a report which stated:
Although proton beam radiation therapy has been shown to be safe and effective for certain tumors that are adjacent to critical structures such as central nervous system (CNS) lesion[s], there is insufficient clinial peer-review[ed] literature for supporting its use of the treatment of breast carcinoma. There [are] other established alternatives available such as conformal or intensity modulated radiation therapy Photon therapy (IMRT) that have been shown to be safe and effective for the adjuvant treatment of breast cancers .... There are several phase I and II clinical trials still evaluating the role of proton therapy for breast cancer. National Comprehensive Cancer Network (NCCN) guidelines also does not include proton therapy as one of the recommended radiation techniques for breast cancer. Per Summary Plan Description, proton therapy for breast cancer is considered I/E because it is the subject of clinical trials. Proton beam radiation therapy, therefore, is a Plan/Benefit exclusion because it is considered I/E per plan language.
(AETNA 303, 314). On October 21, 2019, Aetna issued its "final appeal resolution" of Ms. Prolow's claim, directed to Dr. Fagundes at Baptist Hospital of Miami, stating:
Final level of appeal response - previous determination upheld
With this review, your request for payment of the claim(s) referenced above has reached the final level of appeal available through us. Based on our review of available information, including your appeal, we have made the following determination. We are upholding the original benefits determination for services rendered on the date(s) of service referenced above. Aetna considers proton beam radiation therapy experimental and investigational for Breast cancer because its effectiveness for these indications has not been established.
(AETNA 727). Ms. Prolow proceeded with PBRT treatment as recommended by her treating physicians, paying out-of-pocket for the treatment.
C. Mark Lemmerman: Diagnosis, Treatment and Denial of Claim
Mr. Lemmerman was diagnosed with localized, non-metastatic prostate cancer in January 2020. His radiation oncologist, Dr. Scott Gasiorek, recommended PBRT as an alternative to IMRT, to avoid delivering radiation to critical normal organs and tissues, including the bowel, the bladder, and the rectum (AETNA 1026-1032). Dr. Gasiorek submitted a request to Aetna for PBRT pre-authorization on January 21, 2020 (AETNA 1042-44). On January 22, 2020, Aetna referred the request to "eviCore," a third-party medical review vendor (AETNA 1491, 1496). Approximately one hour after the records were processed at eviCore, the reviewer, Dr. Dorothy Boo, recommended that Aetna deny the request on ground PBRT was not medically necessary, citing CPB 270 and stating that the circumstances of Plaintiff's condition did not warrant an exception to Aetna's policy (AETNA 1492, 1496).
On January 23, 2020, Aetna issued a letter advising Mr. Lemmerman it was denying the request for PBRT authorization because "[m]edical studies do not prove that this procedure (PBRT) is better than other radiation treatment for prostate cancer." (AETNA 1351-56). The letter also stated that the Covanta plan "does not cover experimental or investigational services except under certain conditions." The following day, January 24, 2020 (after the claim was denied), Dr. Boo spoke with Dr. Gasiorek, in response to his request for a peer-to-peer discussion. Following the discussion, Dr. Boo reiterated her recommendation that Aetna's denial determination be upheld.
On February 14, 2020, Dr. Gasioek submitted a first-level appeal of Aetna's decision (AETNA 1387), forwarding medical records and a letter outlining peer-reviewed medical literature and studies supporting his recommendation for PBRT treatment, noting "[r]adiation is a known toxin and there is no benefit whatsoever to depositing radiation in tissue uninvolved with cancer." (AETNA 1027). He included a summary of clinical data relating to the efficacy of PBRT dating back to 1979, along with citations to multiple peer-reviewed literature, including the Internal Journal of Radiation Oncology, Biology, Physics, the Journal of the National Cancer Institute, and the Journal of the American Medical Association ("JAMA") (AETNA 1028-1034), and references to various clinical studies showing the use of PBRT resulted in fewer if any bowel, urinary irritative and/or urinary obstructive symptoms or urinary incontinence (AETNA 1030).
Aetna referred the appeal to AllMed Healthcare Management ("AllMed") (AETNA 1077), where it was reviewed by Dr. Kochanski, a radiation oncologist. Within four hours, Dr. Kochanski recommended that the denial be upheld (AETNA 1070). The AllMed decision acknowledged that the patient has prostate cancer that is non-metastatic, and quoted from CPB 270, stating that Aetna considers PBRT "not medically necessary for individuals with localized prostate cancer because it has not been proven to be more effective than other radiotherapy modalities for this indication." The AllMed report also stated that "the medical documentation does not demonstrate that the patient cannot be treated with photon-based radiation." (AETNA 1071). Aetna accepted AllMed's recommendation and on February 15, 2020 sent a letter to Mr. Lemmerman denying his appeal on the following stated basis:
Based on our review of the above information, we are upholding the previous decision of denial for proton beam treatment ... The basis for this determination is medical necessity criteria is not met per Aetna's Clinical Policy Bulletin [ ]. The member has prostate cancer, no metastasis, and no prior radiation. Aetna considers proton beam radiotherapy not medically necessary for individuals with localized prostate cancer because it has not been proven to be more effective than other radiotherapy modalities for this indication. ... The medical policy does not consider prostate cancer as a diagnosis for which proton beam therapy is necessary over other radiotherapy modalities. Therefore, the requested therapy is not medically necessary.
(AETNA 1058). Mr. Lemmerman submitted a second appeal on April 10, 2020 (AETNA 1076). The following day, Aetna denied the appeal, stating: "Both photon and proton beam radiation are effective at achieving a higher dose of radiation to the cancer without causing so much damage to surrounding tissues with acceptable and similar biochemical control and long-term side effect profiles. The National Comprehensive Cancer Network (NCCN) believes that there is no clear evidence to support a benefit of proton therapy over intensity-modulated radiation therapy (IMRT) for either treatment efficacy or long-term toxicity." (AETNA 1376-1385 at AETNA 1377).
On May 6, 2020, Mr. Lemmerman requested an external review (AETNA 1469, 1474) which Aetna referred to MCMC. On June 17, 2020, MCMC upheld Aetna's denial of coverage, reciting that "the proposed treatment is considered experimental/investigational (E/I) and not medically necessary per plan language for this individual under these unique circumstances." As to the issue of medical necessity, the MCMC reviewer noted that ASTRO and the NCCN recognize lack of clinical evidence showing that PBRT is superior to other forms of radiation treatment, such as IMRT, and stated:
There is emerging data showing that proton beam radiation therapy is safe and effective for the treatment of prostate cancer 1-9. However, there is insufficient clinial peer-reviewed literature that showed that proton therapy is safer and more effective that the standard therapies, which include intensity-modulated radiotherapy (IMRT) .... In fact, several studies have concluded that additional studies are necessary with proton beam radiation therapy for the treatment to prostate cancer.
.....
In addition, American Society for Radiation Oncology (ASTRO) states that "While proton beam therapy is not new technology, its use in the treatment of prostate cancer is evolving. [ASTRO] strongly supports allowing for coverage with evidence development for patients treated in clinical trials or within prospective registries." However, it also concludes that "The comparative efficacy evidence of proton beam therapy is still being developed." National Comprehensive Cancer Network (NCCN) guidelines also state that proton therapy is an option for prostate cancer, but no clear benefit over the existing therapy of intensity-modulated radiation therapy has been demonstrated.
IMRT with photon therapy is the standard of care for patients with prostate cancer that wish to undergo external beam radiation therapy. Proton beam radiation therapy is considered experimental/investigation (E/I) per plan language because it is the subject of ongoing clinical trials. It is not considered medically necessary per plan language because it is more costly compared to photon based IMRT but has not been shown to be clinically superior in well-conducted randomized trials.
(AETNA 1461-62). On June 17, 2020, Aetna wrote to Dr. Gasiorek notifying him of MCMC's decision (AETNA 1454-55). Mr. Lemmerman proceeded with his physician's recommendation to undergo PBRT, paying out-of-pocket for the cost of the treatment (AETNA 1532-1702).
II. STANDARD OF REVIEW
ERISA was enacted "to promote the interests of employees and their beneficiaries in employee benefit plans and to protect contractually defined benefits." Firestone Tire & Rubber Co. v. Bruch , 489 U.S. 101, 113, 109 S. Ct. 948, 103 L.Ed.2d 80 (1989). To this end, ERISA provides a cause of action for a participant or beneficiary of a plan covered under ERISA to bring a civil action "to recover benefits due to him or her under the plan's terms, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." 29 U.S.C. § 1132 (a)(1)(B).
A denial of benefits challenged under ERISA is reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine a claimant's eligibility for benefits, in which case the administrator's decision is reviewed for abuse of discretion. Firestone , 489 U.S. at 115, 109 S.Ct. 948 ; Cosey v. Prudential Ins. Co. of America , 735 F.3d 161, 165 (4th Cir. 2013). Under de novo review, "the court review[s] the employee's claim as it would have any other contract claim – by looking to the terms of the plan and other manifestations of the parties’ intent." Firestone , 489 U.S. at 112-13, 109 S.Ct. 948. Applying the de novo standard, "[t]he Court must consider, based on the record before the administrator at the time its decision was made, whether the court would reach the same decision as the administrator." Glazer v. Reliance Standard Life Ins. Co. , 524 F.3d 1241, 1246 (11th Cir. 2008). In making this determination, no deference is given to the administrator's decision; rather, the Court "stand[s] in the shoes of the administrator and start[s] from scratch, examining all the evidence before the administrator as if the issue had not been decided previously." Bates v. Metro. Life Ins. Co. , 2009 WL 2355834 at *10 (M.D. Ga. 2009). See also Williams v. BellSouth Telecomm., Inc. , 373 F. 3d 1132, 1134-35 (11th Cir. 2004) ; Shaw v. Conn. Gen. Life Ins. Co. , 353 F.3d 1276, 1284 n. 6 (11th Cir. 2003) (citing Moon v. Am. Home Assur. Co. , 888 F.2d 86, 89 (1989) ).
In contrast, when the administrator is conferred discretionary decision-making authority under a plan, its decision is reviewed under an arbitrary and capricious standard of review. To trigger arbitrary and capricious review, "the plan documents at issue [must] explicitly grant the claims administrator discretion to determine eligibility or construe the terms of the plan." HCA Health Services of Ga., Inc. v. Employers Health Ins. Co. , 240 F.3d 982, 993 (11th Cir. 2001) ; Kirwan v. Marriott Corp. , 10 F.3d 784, 789 (11th Cir. 1994) (discretionary authority must be stated in "express language" in the plan document that is "unambiguous in its design to grant discretion regarding entitlements to the fiduciary or administrator"); Moon v. American Home Assurance Co. , 888 F.2d 86, 88-89 (11th Cir. 1989) (discretionary authority cannot be implied but must be expressly given by the plan). See also Perugini-Christen v. Homestead Mortgage Co. , 287 F.3d 624, 626 (7th Cir. 2002) (to lower the standard of review to abuse of discretion, "the plan should clearly and unequivocally state that it grants discretionary authority to the administrator"). Put another way, plenary review is presumed absent clear language to the contrary. Herzberger v. Standard Ins. Co. , 205 F.3d 327, 331 (7th Cir. 2000).
Under the abuse of discretion standard, "the function of the court is to determine whether there was a reasonable basis for the decision based upon the facts as known to the administrator at the time the decision was made." Jett v. Blue Cross & Blue Shield of Ala., Inc. , 890 F.2d 1137, 1139 (11th Cir. 1989). Cf. Helton v. AT & T, Inc. , 709 F.3d 343, 351 (4th Cir. 2013) (court will "affirm a discretionary decision of a plan administrator if it is the result of a ‘deliberate, principled reasoning process’ and is supported by ‘substantial evidence,’ even if [the court] would reach a different decision independently"). In determining whether an administrator's decision-making process was reasonable, courts may not "require administrators automatically to accord special weight to the opinions of a claimant's physician; nor may courts impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physicians’ evaluation." Black & Decker Disability Plan v. Nord , 538 U.S. 822, 834, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003). However, plan administrators "may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician." Id.
The Eleventh Circuit has established the following multi-part test for reviewing a claim administrator's benefits decision under an ERISA plan:
(1) Apply the de novo standard to determine whether the claim administrator's benefits-denial decision is "wrong" (i.e., the court disagrees with the administrator's decision); if it is not, then end the inquiry and affirm the decision.
(2) If the administrator's decision in fact is "de novo wrong," then determine whether [the administrator] was vested with discretion in reviewing claims; if not, end the judicial inquiry and reverse the decision.
(3) If the administrator's decision is "de novo wrong" and [it] was vested with discretion in reviewing claims, then determine whether "reasonable" grounds supported it (hence, review [the administrator's] decision under the more deferential arbitrary and capricious standard).
(4) If no reasonable grounds exist, then end the inquiry and reverse the administrator's decision; if reasonable grounds do exist, then determine if [the administrator] operated under a conflict of interest.
(5) If there is no conflict, then end the inquiry and affirm the decision.
(6) If there is a conflict, the conflict should merely be a factor for the court to consider when determining whether an administrator's decision was arbitrary and capricious.
Where a plan vests the claims administrator with discretion to "construe the terms" of the Plan and determine eligibility for benefits under the Plan, the district court may assume the benefits decision was de novo wrong and begin its analysis at step three. See Mickell v. Bell/Pete Rozelle NFL Players Ret. Plan , 832 Fed. Appx. 586, 591 (11th Cir. 2020) ; Wright v. Reliance Standard Life Ins. Co. , 844 Fed. Appx. 141, 144 (11th Cir. 2021). In this scenario, the claimant bears the burden of proving that he or she is entitled to ERISA benefits and that the administrator's denial was arbitrary and capricious. Wright , 844 F. Appx. at 144 ; Glazer v. Reliance Standard Life Ins. Co. , 524 F.3d 1241, 1247 (11th Cir. 2008).
Blankenship v. Metro. Life Ins. Co. , 644 F.3d 1350, 1355 (11th Cir. 2011).
While this matter is before the Court on cross-motions for summary judgment, in an ERISA benefits denial case "the district court sits more as an appellate tribunal than as a trial court." Curran v. Kemper Nat'l Servs., Inc. , 2005 WL 894840 at *7 (11th Cir. 2005) (quoting Leahy v. Raytheon Co. , 315 F.3d 11, 17 (1st Cir. 2002) ). "It does not take evidence, but, rather, evaluates the reasonableness of an administrative determination in light of the record complied before the plan fiduciary." Id.
For this reason, the summary judgment standard in ERSIA cases is different than the ordinary summary judgment standard applicable in other cases. Ruple v. Hartford Life & Accident Ins. Co. , 340 Fed. Appx. 604, 610 (11th Cir. 2009) (per curiam) ("The usual tests of summary judgment, such as whether a genuine dispute of material fact exists, do not apply"); Jones v. Federal Express Corp., 984 F. Supp.2d 1271, 1275 (M.D. Fla. 2013). In the ERISA context, there "may indeed be unresolved factual issues evident in the administrative record, but unless the administrator's decision was wrong, or arbitrary and capricious, these issues will not preclude summary judgment as they normally would." Pinto v. Aetna Life Ins. Co. , 2011 WL 536443, at *8 (M.D. Fla. 2011) ; Miller v. PNC Financial Services Group Inc. , 278 F. Supp. 3d 1333, 1341 (S.D. Fla. 2017).
III. ANALYSIS
The parties in this case disagree on what standard of review is proper because of their disagreement on what documents constitute the "plan" from which an administrator's discretionary authority could be granted. The parties also have a parallel dispute on whether language found in the Plan Booklets clearly confers discretionary decision-making authority on Aetna. As a result, the parties disagree on (1) whether Aetna's decisions should be reviewed de novo or only for abuse of discretion and (2) whether Aetna's decisions to deny coverage for PBRT were wrong (assuming a de novo standard applies) or whether Aetna abused its discretion (assuming an abuse of discretion standard applies). Pursuant to the Eleventh Circuit's framework set forth in Blankenship , the Court proceeds to consider, first, whether Aetna's decisions were de novo wrong.
A. Whether Aetna's Claim Decisions Were De Novo Wrong
At the first step, the administrator's decision is reviewed de novo to determine whether it was "wrong." The decision is wrong if the Court disagrees with the administrator's decision. Capone v. Aetna Life Ins. Co. , 592 F.3d 1189, 1196 (11th Cir. 2010). More precisely, based on the evidence before the administrator at the time it made its decision, the court evaluates whether it would have reached the same decision. Melech v. Life Ins. Co. of N. America , 739 F.3d 663, 672-73 (11th Cir. 2014) ; Blankenship , 644 F.3d at 1354-55.
1. Precepts of Plan Construction
Like any insurance policy, an ERISA employee welfare benefit health plan is a contract -- an agreement between the Plan and its participants. Salisbury v. Hartford Life & Accident Co. , 583 F.3d 1245 (10th Cir. 2009). Because ERISA itself offers no guidance as to how courts should interpret provisions of an employee welfare benefits plan, federal courts have developed a body of law to govern the interpretation and enforcement of benefit plans in ERISA cases. Alexandra H. v. Oxford Health Ins. Inc. Freedom Access Plan , 833 F.3d 1299, 1306-07 (11th Cir. 2016). See also Firestone Tire & Rubber Co. v Bruch, 489 U.S. 101, 110, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989).
As with any insurance contract, the Court must first look to the language of the plan terms to interpret the contract. Alexandra H. , 833 F.3d at 1307. Contract terms in ERISA policies that are not specifically defined are interpreted according to their "plain and natural" meanings as construed by the average person. Id. at 1307. See also Rasenack ex rel. Tribolet v. AIG Life Ins. Co. , 585 F.3d 1311, at 1318 (10th Cir. 2009) ("Under federal common law, ‘the proper inquiry is not what [the provider] intended a term to signify; rather, we consider the common and ordinary meaning as a reasonable person in the position of the plan participant would have understood the words to mean’ ") (quoting Miller v Monumental Life Ins. Co. , 502 F.3d 1245, 1249 (10th Cir. 2007) ).
Ambiguity exists when a plan provision is reasonably susceptible to more than one meaning, or where there is uncertainty as to the meaning of a term. Alexandra H. , 833 F.3d at 1307. If a plan term is ambiguous, a court conducting a de novo review of an ERISA plan applies the federal common law rule of contra proferentem , which construes all ambiguities against the drafter. Id. at 1307 ; Jones v. Am. Gen. Life & Acc. Ins. Co. , 370 F.3d 1065, 1070 (11th Cir. 2004) ; Florence Nightingale Nursing Serv., Inc. v. Blue Cross/Blue Shield of Ala. , 41 F.3d 1476, 1481 (11th Cir. 1995). Thus, if both the claimant and the administrator propose a reasonable interpretation of a plan, resulting in an ambiguity, under the doctrine of contra proferentem the plan will be construed against the administrator and the administrator's interpretation will be deemed de novo wrong. See Lee v. Blue Cross/Blue Shield of Ala. , 10 F.3d 1547, 1551 (11th Cir. 1994) ; Florence Nightingale Nursing Serv. , 41 F.3d at 1481.
2. Contents of Denial Notice
A number of courts have held that a district court cannot consider a Plan's reason for denying benefits if it was not set forth in the Plan's initial denial. Hall v. Metropolitan Life Ins. Co. , 259 Fed. Appx 589, 593 (4th Cir. 2007). Under this approach, judicial review in an ERISA action may take into account only those reasons for an adverse benefits determination offered in the initial denial notice, because these are the only rationales on which a claimant might have arguably been given a "full and fair" opportunity to respond during the administrative process. Id. ; Abatie v. Alta Health & Life Ins. Co. , 458 F.3d 955, 974 (9th Cir. 2006) ("When an administrator tacks on a new reason for denying benefits in a final decision, thereby precluding the plan participant from responding to that rationale for denial at the administrative level, the administrator violates ERISA's procedures ... Accordingly, an administrator that adds, in its final decision, a new reason for denial, a maneuver that has the effect of insulating the rationale from review, contravenes the purpose of ERISA"); King v. Hartford Life & Acc. Ins. Co. , 414 F.3d 994, 999 (8th Cir. 2005) (district court may not consider a plan administrator's post hoc rationales when reviewing the denial of benefits under ERISA).
Hall explains this result by reference to ERISA's implementing regulations which require that a claimant must initially be provided with, inter alia , "[t]he specific reason or reasons for the adverse determination," and "[r]eference to the specific plan provisions on which the determination is based." 29 C.F.R. § 2650.503-1(g)(i)-(ii). From here, the claimant must then be given "the opportunity to submit written comments, documents, records, and other information relating to the claim for benefits," and the claims administrator must take any such materials submitted into account in deciding the appeal. § 2650.503-1(h)(2)(ii), (iv).
The Court finds this view consistent with ERISA's requirement for employee benefit plans to "provide adequate notice" to any participant or beneficiary whose claim is denied, "setting forth the specific reasons for such denial" in a manner "calculated to be understood by the participant," 29 U.S.C. § 1133 ; Brumm v. Bert Bell NFL Retirement Plan , 995 F.2d 1433, 1436 (8th Cir. 1993), a requirement which prevents claimants from being "sandbagged by a rationale the plan administrator advances only after the suit has been commenced." Jebian v. Hewlett-Packard Co. Employee Benefits Org. Income Prot. Plan , 349 F.3d 1098, 1104 (9th Cir. 2003) ; Marolt v. Alliant Techsystems, Inc. , 146 F.3d 617, 620 (8th Cir. 1998).
In this case, whether the Court limits its consideration to the rationale offered by Aetna in its initial denial letters or at any point during the administrative appeal process, the result is the same and its decisions were de novo wrong for reasons discussed below.
3. Application
Both parties contend that they are entitled to judgment as a matter of law under the de novo standard. Plaintiffs argue that Aetna's decisions are wrong for several reasons: First, they contend Aetna ignored competent medical evidence and data proffered by Plaintiffs’ treating physicians establishing the "medical necessity" of PBRT under the circumstances of their individual cases.
Although Aetna argues that the abuse of discretion standard should apply, in the alternative, it argues its decisions were de novo correct. See Def. Motion at 28 [DE 112].
In the case of Ms. Prolow, they further argue that Aetna never identified a specific bullet point drawn from the Plan's E/I exclusion on which it was relying upon in denying her claim, but instead repeatedly cited Aetna's CPB 270 as the basis for its decision, a guideline which categorically defined PBRT for treatment of breast cancer in adults as E/I "because its effectiveness for [this] indication has not been established."
In the case of Mr. Lemmerman, they argue Aetna denied the claim on the ground of insufficient proof of PBRT's superior efficacy over traditional IMRT, again drawing from CPB 270's more stringent coverage criteria to superimpose a more stringent criterion for coverage and a demonstration of "medical necessity" than that provided in the Plan Booklet. In both cases, Plaintiffs claim Aetna's reliance on CPB NO. 270 to override the terms of the relevant Plan documents was both de novo wrong and unreasonable.
The relevant CPB 270 begins with the statement that PBRT is considered medically necessary for treatment in a few prescribed categories of carcinomas (including any malignancies in persons under age 21); it continues with the statement that PBRT is considered medically unnecessary for treatment of non-metastatic prostate cancer but considered experimental/investigational for treatment of metastatic prostate cancer ; and it concludes with the statement that PBRT is considered "experimental or investigational" in all other (adult) cases, including without limitation "breast cancer," on the stated ground "its effectiveness for these indications has not been established." (AETNA 334-437, at AETNA 335).
The version of CPB 270 in effect in 2020 directed the denial of claims for localized prostate cancer as "not medically necessary" on the stated ground "it has not been proven to be more effective than other radiotherapy modalities for this indication." (AETNA 1111-1235 (5/2020), at AETNA 1112)
CPB 270, however, is not the Alliance Plan or the Covanta Plan: it is simply part of a set of memoranda designed to provide guidance to those interpreting the Plans. The Court must therefore determine whether this guidance, forbidding reimbursement for PBRT to treat breast cancer in adults over age 21, as experimental or investigational, and forbidding reimbursement for PBRT to treat localized prostate cancer as medically unnecessary, is consistent with the terms of the respective Plans.
As a general proposition, third party administrators, like Aetna, "cannot adopt any guidelines they choose and then rely upon these guidelines with impunity; rather, they may rely only upon those guidelines that reasonably interpret their plans." Egert v. Conn. General Life Ins. Co. , 900 F.2d 1032, 1036 (7th Cir. 1990) (citing Reilly v. Blue Cross & Blue Shield United of Wisconsin , 846 F.2d 416 (7th Cir.), cert. denied , 488 U.S. 856, 109 S.Ct. 145, 102 L.Ed.2d 117 (1988) ) (Plan could not grant unfettered discretion to an internal advisory committee to pick and choose which claims would be reimbursed). Here, Aetna argues its interpretation of the Plan terms, guided by CPB No. 270 in interpreting what is considered "experimental and investigational" in the adult breast cancer context, and what is "medically necessary" in the localized prostate cancer context, was a reasonable one, without explaining how CPB No. 270 is consistent with the respective Plan terms. This position raises questions because the Plans do not clearly provide for or preclude reimbursement for PBRT treatments, nor do the Plans mention or purport to incorporate CPB 270. Instead, the Plans simply provide that coverage is available for "medically necessary" health care services prescribed, in the exercise of "prudent clinical judgment," for the purpose of treating "illness, injury, disease or its symptoms."
The parties debate whether it is "reasonable" for Aetna to approve reimbursement for IMRT but to deny reimbursement for PBRT as treatment for cancer, when both procedures, if successful, would achieve the same result. They also debate whether it is reasonable for Aetna to approve reimbursement for PBRT for adults under age 21, while denying it for adults over age 21, and whether it is reasonable to approve PBRT for patients with localized prostate cancer who elect to receive treatment at the Maryland Institute, while denying coverage for patients who receive treatment at other facilities. Even if Aetna acted unreasonably by allowing one form of cancer treatment for patients falling in one age category, while disallowing it for another, this would not necessarily implicate a violation of a plan term and ERISA violation. Such a result could be justified so long as reimbursement for PBRT was specifically excluded in the Plan.
The question the Court must address here, regarding the de novo correctness of Aetna's decision to deny PBRT coverage is whether, in the absence of specific Plan language addressing PBRT coverage , Aetna correctly (or unreasonably) interpreted the Plan terms to deny coverage for Plaintiffs’ claims. Having done so, the Court concludes Aetna's interpretation was de novo wrong, reflecting improper importation of CPB 270 criterion not found in the Policy terms.
First, the Court agrees, as advanced by Plaintiffs, that the Plan definition of "medical necessity" is properly construed in the disjunctive, so that "medical necessity" may be established as long as a treatment prescribed for an illness injury or disease reflects the exercise of "prudent clinical judgment," and meets any one of the five bullet points which follow this base requirement. Because the definition of "medically necessary" fails to include any punctuation between the bullet points, or any words of limitation, conjunction, or disjunction, Plaintiffs argue the language is ambiguous and that this ambiguity must be resolved against the plan drafter and in the light most favorable to the plan participant. Alexandra H. v. Oxford Health , 833 F.3d 1299, 1307 (11th Cir. 2016) (finding, in ERISA context, a plan term to be ambiguous where susceptible to two or more reasonable interpretations).
The Court agrees. Reading these bullet points in the disjunctive, a treatment is "medically necessary" as long as it satisfies the "prudent clinical judgment" threshold and satisfies at least one of the bulleted criteria; for example, a treatment would be covered for a service "that a provider exercising prudent clinical judgment would provide to a patient for the purpose of ... treating an illness ..." where the treatment is also "[i]n accordance with generally accepted standards of medical practice" (first bullet). A claimant satisfying this first bullet need not necessarily establish that the proposed treatment is also "clinically appropriate .... and considered effective for the patient's illness, injury or disease" (second bullet) – which is the apparently the gloss Aetna seeks to place on the definition.
Interpreted in this manner, the evidence in the administrative record unequivocally shows that criteria are satisfied for both Plaintiffs as to bullet one – there is no meaningful dispute that recommendations of Drs. Fagundes and Gasoriek reflected prudent and reasonable clinical judgments which were consistent with "generally accepted standards of medical practice" as that concept is defined in both Plans. PBRT has been approved by the FDA since 1988 "for the treatment of patients with localized tumors and other conditions susceptible to treatment by radiation." A provider exercising "prudent clinical judgment" might provide PBRT to treat non-metastatic breast cancer or prostate cancer, and there is no evidence in the administrative record suggesting that the recommendations of Dr. Fagundes or Dr. Gasoirek reflected imprudent or unreasonable judgments. Nor is there any evidence that their recommendations were inconsistent with "generally accepted standards of medical practice," and Aetna does not expressly take that position in this litigation.
It is undisputed that PBRT has long been an FDA-approved treatment for localized cancer and that Aetna itself considers it clinically appropriate in the treatment of a range of malignancies, including all cancers in children under age 21. The record is replete with evidence showing it is provided at prestigious medical centers throughout the country and contains numerous citations to peer-reviewed medical literature and studies that support the use of PBRT for treatment for non-metastatic prostate cancer and breast cancer in adults (AETNA 286-288, 271-279).
Given the extensive medical literature, detailed medical records, treatment plans and compelling evidence of individual risk factors supplied by Ms. Prolow's and Mr. Lemmerman's treating physicians, the Court concludes that the recommendations of the Plaintiffs’ physicians reflected "prudent clinical judgment" consistent with "generally accepted standards of medical practice," and that this is enough to sustain a finding of "medical necessity" as that concept is properly interpreted under a disjunctive reading of the bullet points employed in its definition. Given this evidence in the administrative record, the Court would not have relied on reports supplied by Aetna's medical reviewers in assessing the claims to reach the conclusion that Mr. Lemmerman's claim was not covered for failure to establish medical necessity (based on insufficient evidence of superior efficacy over other treatment modalities) or to reach the conclusion that Ms. Prolow's claim was excluded from coverage as E/I (based on a claimed lack of proofs on the "established" effectiveness of PBRT for treatment of breast cancer ).
In Mr. Lemmerman's case, Aetna improperly relied on CPB 270 to import a criterion of "superior efficacy" as between alternative treatment modalities into the Plan definition of "medical necessity." As noted, "medical necessity," as defined in Plan, could be established simply by showing a proposed treatment plan reflecting "prudent clinical judgment" which is also consistent with generally accepted standards of care. By imposing a higher criterion of "superior" " efficacy on Mr. Lemmerman, via CPB 270, Aetna adopted an interpretation of the Plan which is de novo wrong. In Ms. Prolow's case, Aetna failed to establish an evidentiary predicate for invocation of the Plan's "experimental / investigational" exclusion, an issue on which Aetna bears the burden of proof. Garcon v. United Mutual of Omaha Ins. Co. , 779 F. Appx. 595, 599-600 (11th Cir. 2019). Plaintiffs contend this provision is ambiguous because it does not "clearly specify who will determine whether a treatment is considered experimental or how that determination will be made." Dahl-Eimers v. Mutual of Omaha Life Ins. Co. , 986 F.2d 1379, 1384 (11th Cir. 1993). In addition, Plaintiffs contend the E/I definition is ambiguous because it is comprised of a list of unpunctuated bullet points, without any signal for a disjunctive or conjunctive connotation, making it unclear if only one or all criteria must be satisfied to trigger the exclusion. Plaintiffs argue this ambiguity must be read against Aetna, as drafter, with the bullets read in the conjunctive for the broadest expansion of coverage. Read in this light, Plaintiffs contend the exclusion is triggered only where there is proof that all listed criteria are satisfied, a showing not made in the extant administrative record.
Mr. Lemmerman's second level appeal was denied on ground that "no clear evidence supports a benefit of proton therapy over intensity modulated radiation therapy for either treatment efficacy or long-term toxicity." As noted, however, the Plan definition of medical necessity does not require a showing of superior efficacy between alternative treatment modalities. Thus, to the extent CPB 270 attempts to import such a criterion it is inconsistent with the express Plan terms and Aetna's reliance upon it resulted in a de novo wrong interpretation and application of the Plan.
Aetna also mentioned the E/I exclusion in its initial denial of Mr. Lemmerman's claim, and again in its external reviewer's decision to uphold Aetna's denial of his claim. The E/I exclusion, however, is not mentioned in Aetna's final denial of the claim.
Aetna argues such a reading would effectively "strip the administrator of substantial (or even any) discretion over the determination that a treatment is experimental or investigational" [DE 125, p. 29], and would be "untenable." Recognizing that it must interpret this provision as a plan participant would reasonably interpret it, the Court agrees that reading the five defining bullet points in the conjunctive would strain a natural, common sense and objectively reasonable interpretation of what constitutes "experimental/investigational" treatment. It is virtually inconceivable that a new medical device or treatment protocol would simultaneously trigger every single indicia of novelty/experimentalism expressed in the E/I bullet points, and no reasonably objective reading of this language by a plan participant would signal such a result.
This does not end the inquiry however, because to rely on the E/I as basis for denial of a claim Aetna must identify which one (or more) of the E/I prongs it relied upon in denying Ms. Prolow's claim, and it must point to evidence in the administrative record demonstrating that the selected criterion was adequately supported. Ms. Prolow argues that Aetna's denial letters never identified any one of the "E/I" bullet predicates as the basis for denying her claim: In its initial denial letter of March 6, 2019, Aetna simply stated "[c]linical studies have not proven that the procedure is effective for treatment of the member's condition" and that "[t]he plan does not cover experimental or investigational services except under certain conditions." In denying her first appeal, it again cited CPB 270 and stated it considered PBRT experimental or investigational for treatment of breast cancer because its effectiveness for this condition has not been established. Its final denial simply repeated this statement regarding the demonstrated effectiveness of PBRT. Because it never properly identified a basis in the Plan document, drawn from the E/I text, for its denial, Plaintiffs argue Aetna's decision to deny coverage based on the E/I exclusion cannot stand and cannot be now invoked to uphold its determination. Additionally, Plaintiffs argue that Aetna's decision on the application of the E/I exclusion is wrong because it reflects Aetna's injection of a new and alternative criterion for an E/I application – an additional bullet allowing for exclusion as E/I simply based on the lack of evidence of "established" effectiveness for treatment of the member's condition. Plaintiffs assert this is a higher standard than that imposed by any of the bullet points found in the Plan's E/I definition, and that injection of this new standard, via CPB 270, was inconsistent with the Plan terms and produced a de novo wrong coverage determination.
In its Opposition Brief to Plaintiff's Motion for Summary Judgment, Aetna disputes this characterization of its denial letters, and takes the position that its initial denial of Ms. Prolow's claim referenced, however obliquely, a deficiency in clinical study data. It also points to findings made at the first level of appeal by its medical reviewer (MRIoA) which more specifically referenced the insufficiency of "outcome data" from clinical trials. Finally, it states that every denial letter in the chain of review made at least a general reference to the E/I exclusion as the basis for Aetna's coverage decision [DE 125 at 23].
As noted in the factual chronology set out above, Aetna's original denial letter on the Prolow claim, issued March 6, 2019, simply stated: "Based on the CPB criteria and the information we have, we are denying coverage for proton beam radiotherapy. Clinical studies have not proven that the procedure is effective for treatment of the member's condition ... (Experimental/Investigatory Denial) This coverage denial was based on the terms of the member's benefit plan document ... The plan does not cover experimental or investigational services except under certain conditions. Please see the reference to experimental or investigational services listed in the Exclusions section of the benefit plan documents." (AETNA 047).
The medical reviewer which Aetna engaged at the first level appeal, MRIoA, did include an oblique reference to "clinical outcome" data in its report to Aetna: "... Although proton radiation is FDA approved for management of malignancy in general, there is insufficient high quality clinical outcomes reported in the peer reviewed medical literature to allow one to make definitive conclusions about the relative safety/efficacy of proton radiation in the member's setting, as compared to standard of care photon radiation ..."(AETNA 229-300).
However, Aetna did not recite that finding in its letter denying the first level appeal, where it instead again generally referred to CPB 270 as the basis for its decision to deny the appeal:
"Based on our review of the information given and Aetna's Clinical Policy Bulletin (CPB) Proton Beam and Neutron Beam Radiotherapy (270) review date May 09, 2018 used for case review, we are upholding the prior denial of coverage. The basis of this determination is that the member did not meet the criteria. As per the CPB noted above, Aetna considers proton beam radiation experimental and investigational for the treatment of breast cancer, as the effectiveness in this condition has not been established. Therefore, criteria are not met, and the previous denial of coverage is upheld." (AETNA 237).
This chronology unequivocally shows that Aetna did not in fact identify the specific "bullet point" of the "E/I" definition on which it was relying in its denial letters and written explanations of its rationale for denying the claim at any point in the review process, contrary to the position advanced by Aetna in its current opposition papers.
While it is true that the E/I exclusion is referenced in Aetna's decision letters, the reference was joined with a quotation or parroting of the language from CPB 270, with the conclusion that the "effectiveness" of PBRT for the patient's indication "had not been established." That is, the E/I reference is not linked to any one of the five specific bullet points defining the exclusion which Aetna has argued, and the Court has found, are appropriately interpreted in the disjunctive. The Court does not view Aetna's vague reference, in its initial denial letter, to unnamed, undated "clinical studies" allegedly bearing on the general efficacy of the treatment for the member's condition sufficient to permit consideration of the first E/I bullet point as a basis for denial of the Prolow claim ("there is not enough outcome data available from controlled clinical studies published in the peer reviewed literature to validate its safety and effectiveness for the illness or injury involved"). And even assuming, arguendo , the Court could consider this prong of the E/I exclusion in passing on the correctness of Aetna's coverage decision, it does not find sufficient evidence in the record to satisfy Aetna's burden of proof upon it. Aetna's oblique reference to the MRIoA reporter's finding of insufficient "high quality" clinical outcomes reported in peer reviewed literature does not even facially address the nuances of this first prong of the E/I exclusion. Finally, in Aetna's cross-motion for summary judgment [DE 115, at 12], it hints at the possibility of triggering the fourth bullet point (treatment is subject of Phase I, Phase II or experimental or research arm of Phase III clinical trial), but it does not – and cannot – contend that this prong of the E/I was ever identified as a basis for denying Ms. Prolow's claim in any of its denial letters to her. The Court therefore does not consider it here.
At page 4 of its initial brief, Aetna quotes the E/I exclusion provisions and adds italics to the first and fourth bullet, hinting at the applicability of both. In the discussion section, it goes on to reference a note in the MCMC reviewer's report stating that several Phase I and II clinical trial are still evaluating the role of proton therapy for breast cancer [DE 115 at 12].
With this, the Court thus concludes Aetna was de novo wrong in determining that coverage for Ms. Prolow was precluded under the E/I exclusion "because its [PBRT's] effectiveness for [this] indication[ ] [breast cancer ] has not been established." Since Aetna's decision on coverage was de novo wrong for both Plaintiffs, the Court must proceed, under Blankenship , to determine the proper standard of review.
B. Whether the Plans Vested Aetna with Discretionary Decision-Making Authority
To determine the proper standard of review, the Court first addresses whether the Plans vested Aetna with discretion to determine eligibility in reviewing claims for PBRT benefits. See Capone v. Aetna Life Ins. Co. , 592 F.3d 1189, 1196 (11th Cir. 2010) ; Melech v. Life Ins. Co. of N. America , 739 F.3d 663, 672-73 (11th Cir. 2014). If Aetna had discretionary authority, then the ultimate question would be whether reasonable grounds supported its decision to deny benefits for each claimant; in other words, whether Aetna's decisions on Plaintiffs’ claims were arbitrary and capricious. If Aetna lacked discretionary authority, however, the Court reverses Aetna's decisions as de novo wrong. Capone , 592 F.3d at 1195.
While the Eleventh Circuit has established that an ERISA claimant bears the burden of proving entitlement to benefits and showing that the administrator's decision was an abuse of discretion, Howard v. Hartford Life & Acc. Ins. Co. , 563 Fed. Appx 658 (11th Cir. 2014), it has not squarely addressed whether the ERISA claimant or the ERISA administrator bears the burden of showing that abuse of discretion is the proper standard of review. Several courts have placed the burden on the administrator, on theory the party claiming deferential review should fairly have the burden of proving the predicate that justifies it. Kinstler v. First Reliance Standard Life Ins. Co. , 181 F.3d 243, 249 (2d Cir. 1999) ; Oliver v. Aetna Life Ins. Co. , 55 F. Supp. 3d 1370, 1378 (N.D. Ala. 2014), aff'd , 613 F. Appx. 892 (11th Cir. 2015). The Court need not decide this issue, however, because regardless of which side has the burden of proof, the Court finds that the Plans do not grant sufficient discretion to Aetna, by clear and express language, to warrant deferential review under the Firestone standard.
The terms that are required to provide discretionary authority to a plan administrator must be stated in "express language" that is "unambiguous in its design to grant discretion regarding entitlement to the fiduciary or administrator." Kirwan v. Marriott Corp. , 10 F.3d 784 (11th Cir. 1994) ; Moon v. American Home Assurance Co. , 888 F.2d 86 (11th Cir. 1989) (discretionary authority cannot be implied from Plan). Thus, this Court is first tasked with "examining the plan documents to determine whether they grant the administrator discretion ..." Tippitt v. Reliance Std. Life Insurance Co. , 457 F.3d 1227, 1232 (11th Cir. 2006) (emphasis added).
1. Whether the Plan Documents Vest Discretionary Authority
Aetna advances two essential arguments in support of its contention that both the Alliance and Covanta Plans conferred discretionary authority upon it over benefit eligibility determinations, thus triggering the arbitrary and capricious standard of review: (1) First, it argues a delegation of discretionary decision making authority was effectively conferred under the Master Services Agreements ("MSAs") entered between Aetna and Plaintiffs’ respective employers; (2) Second, it argues that language in the Plan Booklets is "consistent" with this delegation and independently confers such discretionary decision making authority upon it.
On the latter point, it seemingly recognizes that the Plan Booklets do not expressly confer discretionary authority, but it contends such authority should be implied from language in the Plan Booklets specifying that a claimant is entitled to external review "when we determine" that eligibility does not exist and providing that "we" define medical necessity in the Glossary incorporated in the Plan Booklets. Since the Booklets define "us" to refer to Aetna, they argue Aetna was delegated the authority to make claim eligibility decisions – activity which inherently involves discretionary decision-making authority. For reasons discussed below, the Court finds Aetna's arguments on both counts unpersuasive.
a. Delegation of Discretionary Authority Through Master Service Agreement
For a delegation of discretionary authority to bind plan participants, the delegation must take place in a plan document. 29 U.S.C. § 1102 (a)(1) (2010) (giving plan fiduciaries as named in written instrument authority to control and manage operation of plan). "A ‘plan document’ refers to the written document which sets forth the requirements of every employee benefit plan under 29 U.S.C. § 1102(b) i.e., the document which provides a procedure for establishing and carrying out a funding policy, describes the procedures for the operation and administration of the plan, provides a procedure for amending the plan and for identifying the persons who have authority to amend the plan, and specifies the basis on which payments are made to and from the plan." Schena v. Metro. Life Retirement Plan for U.S. Employees , 2006 WL 3333585, at *3 (M.D. Fla. 2006), aff'd, 244 Fed. Appx. 281 (11th Cir. 2007).
As relevant here, for ERISA purposes a plan document "is one which a plan participant could read to determine his or her rights or obligation under the plan" and not one that merely "memorializes the obligations [the administrator] and Defendant company owed to each other." Local 56, United Food & Commercial Workers Union v. Campbell Soup Co. , 898 F. Supp. 1118, 1136 (D. N.J. 1995) (citing Curtiss-Wright Corp. v Schoonejongen , 514 U.S. 73, 83, 115 S.Ct. 1223, 131 L.Ed.2d 94 (1995) ); Askew v. R.L. Reppert, Inc. , 2016 WL 749945 (E.D. Pa. 2016), aff'd, 721 F. Appx. 177 (3d Cir. 2017) ; Normann v. Amphenol Corp. , 956 F. Supp. 158, 162 (N.D.N.Y. 1997). This is logical implication of ERISA's requirement that "every employee benefit plan be established and maintained pursuant to a written instrument" and that it "specify the basis on which payments are made from the plan," 29 U.S.C. § 1102(a)(1) and (b)(4), a requirement which allows an employee ‘on examining the plan documents to determine exactly what his rights and obligation are under the plan.’ " Whitt v. Sherman Int'l Corp. , 147 F.3d 1325 (11th Cir. 1998) (quoting Curtiss-Wright Corp. v. Schoonejongen , 514 U.S. 73, 82-83, 115 S.Ct. 1223, 131 L.Ed.2d 94 (1995) ).
Plaintiffs argue that the MSAs are not properly considered a part of the "plan documents" issued by either employer, and that the delegation clause in the MSAs purporting to confer discretionary benefits eligibility decision-making authority on Aetna does not bind plan participants such as Lemmerman or Prolow. The threshold issue thus posed is whether a delegation of discretionary authority to a third party -- through a contract which is not referenced in the plan documents -- can vest discretionary decision-making authority which is entitled to deferential judicial review.
It does not appear that the Eleventh Circuit has yet addressed this issue. However, the Seventh and First Circuits have concluded that an administrative service agreement with a third-party administrator is not a "plan document" enforceable against a plan participant or beneficiary where that document is not published to employees and does not set forth rights and obligations of employees under the employee welfare benefit plan. Fritcher v. Health Care Service Corp. , 301 F.3d 811, 817 (7th Cir. 2002) (administrative service agreement (ASA) is not a "plan document" for purpose of holding its terms against a plan participant or beneficiary); Stephanie C. v. Blue Cross Blue Shield of Massachusetts HMO Blue, Inc. , 813 F.3d 420, 429 (1st Cir. 2016) ("[a]ny terms that concern the relationship between the claims administrator and the beneficiaries cannot be held against the beneficiaries where, as here, the terms are in a financing agreement between the employer and the claims administrator that was never seasonably disseminated to the beneficiaries against whom enforcement is sought") (citing Fritcher , 301 F.3d at 816 ). Numerous district courts have followed Fritcher and Stephanie C. on this point. Crider v. Highmark Life Ins. Co. , 458 F. Supp. 2d 487, 518 (W.D. Mich. 2006) (delegation found in separate service agreement, which is not referred to in the Plan documents, is not valid plan document under 29 U.S.C. § 1105(c)(1) ); Miller v. PNC Financial Svs. Group Inc. , 278 F. Supp. 3d 1333, 1350 (S.D. Fla. 2017) ; Erlandson v. Liberty Life Assur Co. of Boston , 320 F. Supp. 2d 501 (N.D. Tex. 2004) (administrative services contract that was not provided to plan participants could not be considered part of ERISA plan); Mirick v. Prudential Ins. Co. , 100 F. Supp. 3d 1094 (W.D. Wash. 2015) ; Rada v. Cox Enterprises Inc. , 2012 WL 3262867, at *4 (D. Nev. 2012) ("the Administrative Services Contract entered by Aetna is not part of the plan, integrated or otherwise, and is not distributed to employees. It does not confer discretionary authority on Aetna for reviewing Plaintiff's claims"); Briscoe v. Preferred Health Plan Inc. , 2008 WL 4146381, at *3 (W.D. Ky. 2008) ; Wimmer v. Hewlett-Packard Co. , 2009 WL 10670689, at *3 (N.D. Ga. 2009) (ASA is not a standard ERISA plan document as it does not establish or delineate the rights of the plan beneficiaries and merely defines the contractual relationship between the employer and the claims administrator").
This Court also finds the rule of Fritcher persuasive, as a consistent extension of ERISA's requirement for Plan documents to be in writing and accessible to participants for the purpose of providing fair notice. Following it here, the Court notes, as a threshold matter, Aetna does not identify any language in the MSAs that describes employee rights and obligations under the Plans. Cf. Anderson v. Blue Cross/Blue Shield of Ala. , 907 F.2d 1072 (11th Cir. 1990) (administrative contract that delegated discretionary authority and defined employees’ benefits and exclusions considered as plan document). Nor does it show that the MSAs were distributed timely to plan members and participants. Cf. Curran v. Kemper Nat'l Services, Inc. , 2005 WL 894840 (11th Cir. 2005) (finding summary plan description (SPD) qualified as plan document where booklet "specifically provided that additional materials describing benefits would be provided to the employee, the SPD described employees’ benefits, and the SPD "was contained in the ‘employee benefits handbook’ and provided to all employees annually.").
Because there is no suggestion that the MSA documents at issue here were freely accessible to employees, and because the MSAs do not set out a description of plan benefits and coverages, the Court does not view these contracts as components of ERISA "plan documents" for purposes of holding their terms against plan participants and determining the proper standard of review. See e.g. Long Island Neurological Associates, P.C. v. Highmark Blue Shield , 375 F. Supp. 3d 203, 207 (E.D.N.Y. 2019) (for ERISA purposes, a plan document is one which a plan participant could read to determine his or her rights or obligations under the plan, and not one that merely memorializes the obligations owed between the administrator and defendant company); Miller v. PNC Financial Services Group, Inc. , 278 F. Supp 3d 1333, 1351 (S.D. Fla. 2017) (delegation of authority in administrative services agreement not referenced in plan document could not "constitute a grant of discretion such that judicial review of the third party's ERISA determination is reviewed only for abuse of discretion").
The cases cited by Aetna as authority for a district court to "reach beyond" the Plan Booklet in defining the contours of an ERISA Plan, to capture a relevant Administrative Service Agreements ("ASA") as part of the mix, are either factually distinguishable or analytically inapposite. See e.g. Dowling v. Metropolitan Life Ins. Co. , 355 F. Supp. 2d 1311 (M.D. Fla. 2004) (referencing ASA as part of Plan Documents, without discussion, while also quoting from Plan language which authorized defendant to "assume [ ] the regulatory and discretionary authority for approving or denying Plan benefits" and for reversing benefits decision); Kinser v. Plans Administration Committee of Citigroup, Inc. , 488 F. Supp 2d 1369, 1378 (M.D. Ga. 2007) (finding ASA to be proper "plan document" where ASA was incorporated into plan by language defining the plan as a "welfare program" comprised of "arrangement [of] plan documents, insurance policies, third party administrative contracts .. and other descriptive materials" incorporated into the Plan); Klebe v. Mitre Health Care Plan , 894 F. Supp 898, 902 (D. Md. 1995) (referencing ASA as part of the Plan Document without discussion); Aschermann v. Aetna Life Ins Co. , 2010 WL 4778724, at *3 (S.D. Ind. 2010), aff'd , 689 F.3d 726 (7th Cir. 2012) (purporting to distinguish Fritcher by reference to substantive content of ASA in the case before it, while failing to address Fritcher ’s separate rejection of an ASA as a "Plan document" on the ground it was not published to employees); Semien v. Life Ins. Co. of N. America , 436 F. 3d 805, 811 (7th Cir. 2006) (noting that the Plan Booklet itself recited that the plan administrator has "sole discretion" to apply and construe plan provisions and to grant or deny claims for benefits).
In this case, the relevant Plan Booklets do not refer to or incorporate the third-party MSAs; there is no indication that the MSAs were published to plan members or beneficiaries (outside of production made in this lawsuit); and the MSAs do not define the rights and obligations of the plan members. Rather, they define contractual rights and obligations as between Aetna and each respective "Customer" (employer). In this scenario, following the Seventh and First Circuit's approach outlined in Fritcher and Stephanie C. , the Court concludes that the MSAs are not properly considered "Plan Documents," and thus concludes that plan beneficiaries -- such as Ms. Prolow and Mr. Lemmerman – are not bound by the MSA terms.
b. Whether the Plan Booklets (Standing Alone) Confer Discretionary Authority
To confer discretionary authority to a plan administrator effectively, a plan document must contain "express language" that is "unambiguous in its design to grant discretion regarding entitlements to the fiduciary or administrator." Kirwan v. Marriott Corp. , 10 F.3d 784, 789 (11th Cir. 1994) ; Moon v. American Home Assurance Co. , 888 F.2d 86, 88-89 (11th Cir. 1989) (discretionary authority cannot be implied from the plan but must be expressly given by the plan). The Court's inquiry here thus begins with an examination of the plan booklets to determine whether they expressly grant Aetna discretionary decision-making authority to interpret the plan terms and make eligibility determinations. Tippitt v. Reliance Standard Life Ins. Co. , 457 F.3d 1227, 1232 (11th Cir. 2006).
Aetna contends the Plan Booklets do "expressly reflect" a grant of discretion to it in claims eligibility determinations. The booklets concededly contain no language expressly stating as much, but Aetna intimates this authority inherently attaches to its delegated role as arbiter of medical necessity issues. Here, it points to language in the booklets requiring precertification for coverage for certain services, a process which "may include a determination by us (Aetna) as to whether the services is medically necessary and eligible for coverage," language which give members a right to external review where "we" (defined as Aetna) have decided the service or supply is not medically necessary or appropriate"), and language referencing its control over the definition of medical necessity ("the medical necessity requirements are stated in the Glossary section, where we define ‘medically necessary, medical necessity.’ That is where we also explain what our medical directors or their physician designees consider when determining if an eligible health service is medically necessary.")
Aetna claims this language implies the conferment of discretionary authority to make claims eligibility decisions on the theory that these decisions necessarily include a component of medical necessity. For this proposition, it cites Anderson v. Blue Cross /Blue Shield of Alabama , 907 F.2d 1072, 1076 (11th Cir. 1990), where the Eleventh Circuit applied an abuse of discretion standard in a case involving a third party administrative contract which gave the administrator the right to determine which services and supplies were medically necessary and therefore payable, and the right to determine amounts to be paid as "reasonable and customary fees" to physicians performing a service or procedure on a member. In Anderson , the Eleventh Circuit considered the ability to exercise such "discretionary power" to suffice, under Firestone , to trigger review for arbitrariness and caprice rather than de novo review.
The Court does not agree that the Plan language at issue here is controlled by Anderson . In Anderson , the appellate court did not quote the exact plan language delegating the ability to determine medical necessity; nor did it suggest that a conferment of authority to determine medical necessity in any context (precertification vs. final claims denial) inherently involves a grant of discretionary decision-making authority on eligibility. Nor could such a conclusion be drawn consistent with the holding of Firestone .
The plan language at issue here is more closely aligned with that at issue in Kirwan , where the Eleventh Circuit reiterated the requirement that discretionary authority to be "expressly given" by a plan in order to trigger the abuse of discretion standard. Kirwan v. Marriott Corp. , 10 F.3d 784 (11th Cir. 1994). In Kirwan , the plan gave Marriott the "authority to control and manage the operation and administration of the Plan" and the "authority to promulgate the rules and regulation [ ] deemed necessary and proper to interpret or administer the Plan," but it did not specifically grant Marriott the authority to deny claims. So too, in this case, the Plan documents seemingly recognize Aetna's authority to define medical necessity, and to participate in making "medical necessity" determinations at the precertification stage, but there is no language in the Plans which specifically grants it discretionary authority to make final eligibility decisions.
Almost all ERISA plans designate an administrator who, to carry out its duties under the plan, must determine whether a participant is eligible for benefits, yet this authority to make eligibility determinations does not carry with it the requisite discretion under Firestone unless the plan so provides. Gallagher v. Reliance Std. Life Ins. Co. , 305 F.3d 264, 269 (4th Cir. 2002). Firestone recognizes this distinction: The Supreme Court there drew a contrast between trustees who had no discretion but who had authority to manage a trust, and trustees who had been granted discretion in addition to their authority. Firestone , 489 U.S. at 111, 109 S.Ct. 948. See also Haley v. Paul Revere Life Ins. Co. , 77 F.3d 84, 88 (4th Cir. 1996) (noting difference between authority/duty to pay benefits and grant of discretion over benefit determinations) This distinction is critical because ERISA plans, when ambiguous, must be construed in accordance with the reasonable expectations of the insured, and reliance on extrinsic documents to define Plan content would foster uncertainty about employee benefits, rather than furthering ERISA's goal of ensuring that employee's rights and obligations can be readily ascertained from the plan documents.
In short, "[a] plan which simply conveys authority to an administrator creates the expectation only that such authority will be exercised, not that the administrator will enjoy wide discretion in wielding its authority as well as freedom from searching judicial inquiry." Woods v. Prudential Ins. Co. of America , 528 F.3d 320, 323 (4th Cir. 2008). This Court draws this distinction between authority and discretionary authority, finding it logically consistent with ERISA's notice requirements to plan employees.
As aptly expressed by the Seventh Circuit in Herzberger v. Standard Ins. Co. , 205 F.3d 327, 332 (7th Cir. 2000) :
We hold that the mere fact that a plan requires a determination of eligibility or entitlement by the administrator ... does not give the employee adequate notice that the plan administrator is to make a judgment largely insulated from judicial review by reason of being discretionary. Obviously, a plan will not -- could not, consistent with its fiduciary obligation to the other participants – pay benefits without first deciding that the applicant was entitled to them. The statement of this truism in the plan document implies nothing one way or the other about the scope of judicial review of his determination, any more than our statement that a district court "determined" this or that telegraphs the scope of our judicial review of that determination.
In this case, there is nothing in the language of the Plan Booklets from which the grant of discretionary authority to make claims eligibility determinations may logically be derived. The simple reference to Aetna's role in making "decisions" on medical necessity in precertification process, or in defining medical necessity in general, do not necessarily imply conferment of discretionary authority to deny claims. Or, as Plaintiffs express it, plan language contemplating that an administrator will conduct certain activities (e.g., determine benefit eligibility) is not the same as language which grants the administrator discretionary authority to conduct those activities. See Kirwan v. Marriott Corp. , 10 F.3d at 788.
The contrary position advanced by Aetna – that the bare assignment of decision-making authority over medical necessity issues creates a Firestone -type discretion – would lead to an abuse of discretion standard of review whenever an administrator is vested with authority to make benefit eligibility determinations. This is not the holding of Anderson . Because an administrator always possesses such authority, Aetna's argument would lead to an abuse of discretion review in virtually every ERISA benefits case, effectively eliminating Firestone ’s distinction between authority and discretionary authority. Aetna does not proffer a single case that construes Anderson to allow abuse of discretion review over the decision of an administrator vested with authority to define medical necessity, and to control the precertification process, without also conferring discretionary authority to determine ultimate benefit eligibility questions.
Because there is no language in either Plan Booklet or any other "Plan Document" vesting Aetna with discretionary authority to make claims eligibility determinations, the Court concludes that Aetna's denial of Plaintiffs’ claims must be reviewed de novo. Because the Court has already found that Aetna's decision to deny PBRT coverage was de novo wrong as to both Ms. Prolow and Mr. Lemmerman, it must now "end the inquiry" and reverse Aetna's decision to deny PBRT benefits. See Capone , 592 F.3d at 1195.
IV. CONCLUSION
Based on the foregoing, it is ORDERED AND ADJUDGED:
1. Plaintiffs’ Motion for Partial Summary Judgment [DE 110] is GRANTED . The parties are directed, within 10 days from the entry
of this Order, to submit to the Court their respective positions on when and how the Court should proceed to determine the amount of damages to which the putative class representatives are entitled.
2. Given the Court's ruling establishing de novo error in Aetna's substantive claim denial, it is unnecessary to reach Plaintiffs’ alternative challenge to Aetna's decisions under the arbitrary and capricious standard of review. It is also unnecessary to reach Plaintiffs’ challenge to the adequacy of Aetna's claims handling and review procedures and the argument that Aetna failed to provide a full and fair review of Plaintiffs’ claims in violation of ERISA's procedural requirements.
3. Defendant's Motion for Summary Judgment [DE 112] is DENIED.
4. This case shall proceed to the class certification processes and trial on the remaining issues pursuant to the Court's extant Scheduling Order.
DONE AND SIGNED in Chambers at West Palm Beach, Florida this 27th day of January, 2022.