UNIVERSITY SPINE CENTER v. CIGNA HEALTH AND LIFE INSURANCE COMPANY
2:17-cv-09226
| D.N.J. | Sep 3, 2019Background
- Patient (an employee covered by UBS’s ERISA Benefits Plan) underwent epidural injection in June 2013 and lumbar surgery (including codes 22633 and 20930) in August 2013 performed by physicians at University Spine Center; Cigna was the plan’s third-party claims administrator.
- Cigna paid limited amounts for the services and denied additional reimbursement for certain procedure codes as not medically necessary under its Coverage Policy 0303 (lumbar fusion criteria).
- Dr. Emami (as patient’s attorney-in-fact) appealed Cigna’s medical-necessity denials through the plan’s internal process; Cigna denied at the first level and an independent external reviewer upheld the denial on lack of objective findings and insufficient conservative treatment.
- University Spine Center (later Dr. Emami as assignee/attorney-in-fact) sued under 29 U.S.C. § 1132(a)(1)(B) seeking benefits; all parties moved for summary judgment.
- Court applied ERISA exhaustion rules and the arbitrary-and-capricious standard (Plan grants Cigna discretionary authority) and granted Defendants’ motions, denying Plaintiff’s.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| 1. Whether Plaintiff exhausted administrative remedies for claims by Drs. D’Amato and Sinha | Appealed for Emami’s bill; argues futility should excuse exhaustion for Sinha | No evidence of any appeal for D’Amato or Sinha; futility not shown | Court: Plaintiff failed to exhaust for D’Amato and Sinha; summary judgment for Defendants on those claims |
| 2. Whether Cigna’s denial of Emami’s surgical codes was arbitrary and capricious | Emami contends treatment substantially complied with Cigna’s guidelines and policy usage was improper/extrinsic | Cigna relied on Policy 0303 (authorized by Plan) and independent review; lack of radiographic spondylolisthesis, inadequate conservative treatment, and smoking status not shown | Court: Cigna’s use of Policy 0303 was within discretion; denial supported by substantial evidence; grant Defendants’ summary judgment |
| 3. Whether plan administrator must give special weight to treating physician | Treating physician’s opinion should control | Plan and precedent permit administrator to credit independent reviewers over treating physician | Court: No special weight required to treating physician; Cigna permissibly relied on its reviewers |
| 4. Whether other procedure codes were improperly denied (e.g., integral codes) | Plaintiff challenges denial of additional codes as arbitrary | Plaintiff only administratively appealed medical necessity; other-denial bases were not appealed | Court: Plaintiff failed to exhaust administrative remedies regarding those codes; summary judgment for Defendants |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989) (establishes standard of review for ERISA plan interpretations and administrator discretion)
- McLeod v. Hartford Life & Acc. Ins. Co., 372 F.3d 618 (3d Cir. 2004) (arbitrary-and-capricious review applies where plan grants discretion)
- Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003) (administrator not required to accord special weight to treating physician)
- Anderson v. Liberty Lobby, 477 U.S. 242 (1986) (summary judgment standard regarding genuine issues of material fact)
- Celotex Corp. v. Catrett, 477 U.S. 317 (1986) (summary judgment burdens of production)
- Abnathya v. Hoffmann-La Roche, Inc., 2 F.3d 40 (3d Cir. 1993) (arbitrary-and-capricious standard explained)