Devers v. Carpenters Health and Welfare Trust Fund for California, 3:18-cv-04215

Background

Plaintiff Jessica Devers, a beneficiary of the Carpenters Health & Welfare Trust Fund, sought coverage for Chemet (a chelating agent) to treat skin lesions from Grover’s disease; the Plan requires prior approval for certain drugs and permits off-label use if PBM (Express Scripts) grants prior approval.
Initial request for Chemet was denied by Express Scripts on November 26, 2017; Devers appealed and submitted medical evidence including a Dantzig paper, urine heavy‑metal test, and a treating‑clinician statement that Chemet was the only effective treatment.
Express Scripts issued a written denial of Devers’s appeal on December 15, 2017, but the Trustees (Carpenters) did not have or consider that denial and proceeded to hear the appeal themselves on January 11, 2018.
The Trustees denied the appeal on January 11, 2018, citing lack of medical necessity under the Plan’s exclusion for drugs not reasonably necessary, but provided no explanation of the scientific or clinical judgment supporting that finding as required by ERISA regulations and the SPD.
Devers sued under ERISA § 502(a); the parties agreed the substantive denial should be reviewed for abuse of discretion, and the district court tried the case on the administrative record.
The court found no evidentiary support in the administrative record for the Trustees’ no‑medical‑necessity conclusion and found affirmative evidence supporting medical necessity; it denied defendants’ summary judgment and granted Devers’s judgment, awarding benefits and directing the parties to meet and confer on remedy, fees, and injunctive relief.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Which decision is the final administrative decision for review?	Trustees’ January 11, 2018 denial is the operative final decision because the Trustees heard and decided the appeal.	Express Scripts’ December 15, 2017 denial was the final decision because PBM normally handles drug appeals and denied prior approval for off‑label use.	Held for Devers: Trustees’ denial is the operative administrative decision because Trustees independently heard the appeal and did not rely on Express Scripts’ denial; Express Scripts’ decision was not in the Trustees’ record.
Was the Trustees’ denial supported by the administrative record (medical necessity)?	Chemet is medically necessary: Dantzig article, high urine heavy‑metal levels, treating clinician’s letter, and Plan’s prior coverage of Chemet support necessity.	Trustees reasonably concluded Chemet was not medically necessary.	Held for Devers: No evidence supports lack of medical necessity; record supports medical necessity.
Did the Trustees comply with ERISA procedural requirements (explain scientific/clinical judgment)?	Plan and ERISA regs require explanation when denial is based on medical necessity; Trustees failed to provide required explanation.	Procedural defects are not outcome‑determinative; denial stands.	Held for Devers: Trustees violated 29 C.F.R. § 2560.503‑1(g)(1)(v)(B) and the SPD by failing to explain scientific/clinical judgment; that procedural violation constituted an abuse of discretion.
Remedy — remand or judgment awarding benefits?	Given absence of contrary evidence, award benefits rather than remand; order parties to confer on amount and fees.	Remand to plan for clarification and compliance.	Held for Devers: Court awarded judgment for benefits (no remand) because record contains no basis to uphold denial; directed meet and confer on benefits, fees, and any injunctive relief.

Key Cases Cited

Anderson v. Liberty Lobby, Inc., 477 U.S. 242 (summary judgment standard)
Celotex Corp. v. Catrett, 477 U.S. 317 (summary judgment and burdens)
Kearney v. Standard Ins. Co., 175 F.3d 1084 (9th Cir. 1999) (trial on administrative record in ERISA cases)
Stephan v. Unum Life Ins. Co. of Am., 697 F.3d 917 (9th Cir. 2012) (abuse‑of‑discretion deferential standard for plan decisions)
Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955 (9th Cir. 2006) (procedural failures can warrant de novo review or constitute abuse of discretion)
Chuck v. Hewlett Packard Co., 455 F.3d 1026 (9th Cir. 2006) (remand is typical remedy for ERISA procedural violations)
Johnson v. Trustees of W. Conference of Teamsters Pension Tr. Fund, 879 F.2d 651 (9th Cir. 1989) (abuse of discretion if decision rendered without explanation)