Katherine P. v. Humana Health Plan, Inc., 959 F.3d 206

Katherine P. received partial hospitalization program (PHP) treatment for an eating disorder at Oliver‑Pyatt Centers for ~3 months; Humana paid for the first 12 days and denied the remainder as not “medically necessary” under the plan.
The plan defined “medically necessary” by several criteria, including conformity with nationally recognized standards and reliance on credible scientific evidence.
Humana applied the Mihalik Criteria (ED.PM.1–4) for PHP coverage and concluded Katherine failed ED.PM.3 and ED.PM.4 (specifically ED.PM.4.2).
Katherine sued under ERISA § 1132(a)(1)(B); the district court adopted the magistrate’s recommendation and granted summary judgment to Humana.
On appeal the Fifth Circuit reviewed de novo (no valid delegation of discretion was asserted) and concluded there is a genuine factual dispute as to ED.PM.4.2 (whether less intensive treatment had been unsuccessful), so summary judgment was improper.
The Fifth Circuit vacated and remanded for further proceedings, limiting its ruling to ED.PM.4.2 and leaving procedural details to the district court’s discretion.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Standard of review	De novo review (no valid discretionary delegation)	Humana suggested abuse‑of‑discretion review (waived)	De novo review applies; Humana waived discretionary‑clause argument
Procedural vehicle: summary judgment vs. bench trial	Summary judgment was acceptable (parties assumed it)	Same	Court did not decide the broader question; proceeded on summary judgment record
Whether PHP was “medically necessary” under plan/Mihalik Criteria	Katherine contended she met ED.PM.4.2: less intensive care previously unsuccessful (declarations, physician statements)	Humana concluded ED.PM.4.2 not met and denied coverage	Genuine factual dispute about ED.PM.4.2 precludes summary judgment; remand required
Weight of treating physicians / potential reviewer conflict	Treating opinions and declarations support plaintiff’s case	Humana relied on reviewers and Mihalik analysis	Treating opinions are competent evidence but not entitled to special weight (citing Nord); court did not resolve conflict issue on appeal

Ariana M. v. Humana Health Plan of Texas, Inc., 884 F.3d 246 (5th Cir. 2018) (framework for ERISA review of benefits denials)
Anderson v. Liberty Lobby, Inc., 477 U.S. 242 (1986) (summary judgment standard)
Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003) (treating‑physician opinions are not entitled to special deference in benefit determinations)
Kearney v. Standard Ins. Co., 175 F.3d 1084 (9th Cir. 1999) (discussing review of administrative record and findings without a full trial)
Dialysis Newco, Inc. v. Cmty. Health Sys. Grp. Health Plan, 938 F.3d 246 (5th Cir. 2019) (review of district court’s grant of summary judgment in ERISA cases)
Nichols v. Reliance Standard Life Ins. Co., 924 F.3d 802 (5th Cir. 2019) (summary judgment standards in ERISA context)