A. v. United Healthcare Insurance et al

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF UTAH
M.A., individually and on behalf of Z.A., a
minor,
Plaintiffs,
v.
UNITED HEALTHCARE INSURANCE
COMPANY; UNITED BEHAVIORAL
HEALTH; and KAISER ALUMINUM
FABRICATED PRODUCTS WELFARE
BENEFIT PLAN,
Defendants.
MEMORANDUM DECISION AND
ORDER GRANTING DEFENDANTS’
MOTION FOR SUMMARY JUDGMENT
AND DENYING IN PART AND
GRANTING IN PART PLAINTIFFS’
MOTION FOR BENEFITS AND AN
AWARD OF ATTORNEY FEES
Case No. 1:21-cv-00083-JNP
Chief District Judge Jill N. Parrish
This action arises under the Employee Retirement Income Security Act of 	1974
(“ERISA”), 29 U.S.C. § 1001, et seq., and the Mental Health Parity and Addiction Equity Act of
2008 (“Parity Act”), 29 U.S.C. § 1185a. Plaintiffs seek recovery of benefits under 29 U.S.C. §
1132(a)(1)(B) (the “ERISA Claim”).0F
1 See ECF No. 68. In September of 2023, the court remanded
the action to Defendants after finding that Defendants’ claim denials were arbitrary and capricious.
ECF No. 65 at 19. On remand, Defendants upheld the denial of benefits.
Presently before the court are the parties’ cross-motions for summary judgment. ECF Nos.
68, 77. Having considered the parties’ arguments and the record, Plaintiffs’ motion for summary
1 In the pre-remand proceedings, Plaintiffs also alleged a violation of the Mental Health Parity and
Addiction Equity Act. The court opted to not address that claim in its September 2023 Order on
account of it being premature. ECF No. 65 at 19–20. Plaintiffs do not again raise the claim, and
the parties did not brief the issue.
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judgment (entitled a “Renewed Motion for Benefits, Attorney Fees, Prejudgment Interest, and
Costs”) is denied in part and granted in part, and Defendants’ motion for summary judgment is
granted.
FACTUAL AND PROCEDURAL BACKGROUND
I. 	Pre-Remand Factual Background
The court generally recites the facts as stated in its March 2024 Order. See M.A. behalf of
Z.A. v. United Healthcare Ins., No. 1:21-CV-00083-JNP-DBP, 2023 WL 6318091 (D. Utah Sept.
28, 2023).
Defendants United Healthcare Insurance, United Behavioral Health, and Kaiser Aluminum
Fabricated Products Welfare Benefit Plan (the “Plan”) (collectively, “Defendants”) denied benefits
allegedly due to Plaintiffs under the Plan, which is an ERISA-governed plan. ECF No. 65 at 1–2.
At all relevant times, M.A. was a Plan participant and his daughter Z.A. was a Plan beneficiary,
while Kaiser was the Plan administrator and United Healthcare was the designated claims
administrator. ECF No. 2 ¶ 3; AR 12167, 12175. Plaintiffs obtained mental health care for Z.A. at
BlueFire Wilderness Therapy (“BlueFire”) between June 4, 2018 and August 8, 2018 and at Uinta
Academy (“Uinta”), a residential treatment center (“RTC”), between August 9, 2018 and August
27, 2019. ECF No. 2 ¶ 4. Plaintiffs claim Defendants’ wrongful denial of benefits for this care
caused them to incur $230,000 in unreimbursed medical expenses. ECF No. 2 ¶ 61.
A. 	The Plan
The Plan offers benefits for medically necessary covered health services. AR 12168,
12172–73. For a treatment to be medically necessary under the Plan, it must correspond to the
patient’s needed level of care. AR 12171, 12173. The Plan gives Defendants discretion to interpret
the Plan’s terms and make factual determinations regarding Plan coverage. AR 12162.
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The Plan excludes coverage for experimental or unproven services. AR 12123–24. United
Healthcare 	created 	a 	Wilderness 	Therapy 	Behavioral 	Clinical 	Policy 	(the 	“Policy”) 	that
categorized wilderness therapy as an unproven treatment excluded from Plan coverage. AR 9168–
72. United Healthcare reviewed Plaintiffs’ claim for Plan benefits for Z.A.’s care at BlueFire under
this Policy. AR 4784–85. Unlike wilderness therapy, RTC care is medically necessary under the
Plan so long as the insured requires 24/7 treatment for symptoms that interfere with her safety or
the safety of others or would prevent treatment at a less intensive level of care. AR 9215–16. A
Plan participant must obtain prior authorization for out-of-network RTC care to have that treatment
covered. AR 12074, 12100. United Healthcare used its Optum level of care guidelines to review
Plaintiffs’ claim for benefits for Z.A.’s treatment at Uinta. AR 4786–87, 9203–37.
B. 	Z.A.’s Condition and Treatment
Z.A.’s mental health declined in sixth grade. AR 178. In seventh grade, her parents learned
she was engaging in self-harm and writing suicidal thoughts online. AR 178, 256. The next year,
Z.A.’s situation worsened. She began using drugs and alcohol and was hospitalized repeatedly for
attempted overdoses and other self-harm. AR 179–80, 202, 216. Z.A. became so disruptive at
school that her assistant principal identified her need for intensive mental health support. AR 179–
83, 201–10, 212, 215, 256. Z.A.’s parents sought support for her, and she began counseling in
seventh grade. Her therapist, Dr. Pat Sharp, diagnosed her with persistent depression and
generalized anxiety. AR 178–80, 218.
After a year of counseling with Dr. Sharp, Z.A. was transferred to a new therapist, Dr.
Jeanette Higgins, who diagnosed Z.A. with “depressive disorder, a parent-child relationship
problem, social exclusion or rejection, and a provisional diagnosis of a bipolar and related
disorder.” Id. In eighth grade, Z.A. began an intensive outpatient counseling program, but her
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situation worsened. Z.A.’s school suspended her indefinitely because the district could not meet
her mental health needs. AR 139, 181. Dr. Higgins then recommended residential treatment, which
she believed necessary based on Z.A.’s need for an intensive intervention that included continuous
monitoring. AR 218.
Z.A.’s parents admitted her to BlueFire on June 4, 2018. AR 89. There, Z.A. saw therapists
Shannon Kerrick and Amanda Stone, who diagnosed her with “major depressive disorder and
generalized anxiety disorder, as well as parent-child relational problems.” AR 139–40, 171, 254.
Kerrick noted that Z.A.’s progress at BlueFire was slow and recommended continuing RTC
treatment after leaving BlueFire. AR 254. Z.A. was discharged from BlueFire on August 8, 2018
and admitted to Uinta the following day. AR 552.
At Uinta, Z.A. initially denied her past self-harm and suicide attempts, but she was still
monitored every fifteen minutes throughout the night. AR 548–49, 560. This close supervision
continued when her risk level was downgraded slightly in September of 2018, and did not end
until sometime after March of 2019. AR 368–69, 372, 260, 279, 302, 308, 1329, 1382. While at
Uinta, Z.A.’s treatment notes reflected some positive periods, see, e.g., AR 446, 455, 457, 491,
886, and some negative periods, see, e.g., AR 449–50, 497, 500. During this time, Z.A. was
diagnosed with depressive disorder, generalized anxiety disorder, and dependent personality
disorder traits. AR 873, 1025. In December of 2018, her treatment team noted “modest
improvements in her depression” but continued “high anxiety[,]” and in March of 2019, her
treatment team wrote she was in a “preparation stage of change.” AR 1342–42. When her progress
stalled, however, her treatment team advised continued treatment out of concern that without it,
Z.A. would relapse into “worse and dangerous behaviors.” Id. Z.A. continued treatment at Uinta
until she was discharged on August 27, 2019.
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C. 	Denial of Benefits and Prelitigation Appeals — BlueFire
Plaintiffs did not seek prior authorization for Z.A.’s treatment at BlueFire, an out-of-
network provider. AR 47. When Plaintiffs sought coverage, Defendants denied their claim due to
non-timely receipt of Z.A.’s medical records. AR 45, 89–90. Plaintiffs submitted an initial internal
appeal of this decision, stating they had already provided Z.A.’s medical records. Id. On February
14, 2019, Defendants responded, upholding their denial of benefits, but on different grounds. Dr.
Kenneth Fischer, the reviewing physician, concluded Z.A.’s care at BlueFire was not covered by
the Plan due to the wilderness therapy Policy, because BlueFire didn’t meet the definition of an
RTC, and because Z.A.’s care was not medically necessary. AR 47, 1813–14.
On April 2, 2019, Plaintiffs submitted a second appeal of Defendants’ denial of coverage
for Z.A.’s care at BlueFire. AR 1789–2774. Along with their appeal, Plaintiffs attached BlueFire’s
license, peer-reviewed literature contesting Defendants’ claim that wilderness therapy is an
unproven treatment, and letters of medical necessity supporting Z.A.’s claim for benefits from Dr.
Alison LaFollette, Dr. Higgins, and other treatment providers and school administrators. AR 1852–
53, 2004–2729, 2767, 2769, 2771, 2773. Defendants denied this second appeal in a pair of letters
dated May 3, 2019 and July 24, 2019. AR 4786–88, 9151–52. These letters relied on opinions from
reviewing physicians Dr. Howard Wong and Dr. Sonya Jones, both of whom concluded that Z.A.
was in wilderness therapy, which was beyond Plan coverage, and that her treatment at BlueFire
was not medically necessary. AR 4786–88. Dr. Wong specifically noted his conclusion that Z.A.
was not “reported to be dangerous to herself or others[,]” could “look after her day to day needs[,]”
and “did not have clinical issues requiring 24/7 monitoring.” Id. Similarly, Dr. Jones concluded
Z.A. had stable “medical and mental health[,]” could “take care of her needs[,]” and “did not
require 24-hour care[.]” AR 9151–52.
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Plaintiffs requested an external review of Defendants’ claim denials for Z.A.’s treatment at
BlueFire. AR 4781–6905. The external reviewer upheld Defendants’ decision. AR 9175–79. The
reviewer based this decision on an unnamed reviewing physician’s opinion that Z.A.’s care at
BlueFire was not medically necessary. AR 9178. The external reviewer did not discuss the
wilderness therapy Policy as another justification for denying benefits. Id.
D. 	Denial of Benefits and Prelitigation Appeals — Uinta
On August 21, 2018, Defendants denied Plaintiffs’ claims for Plan coverage of Z.A.’s
treatment at Uinta. AR 195–96. Reviewing physician Dr. Jeffrey C. Uy based this decision on his
conclusion that her treatment there was not medically necessary. Id.
Plaintiffs submitted a first appeal of this denial on December 28, 2018. AR 176–644.
Plaintiffs attached letters attesting to the medical necessity of her treatment at Uinta from Dr.
LaFollette and from Shannon Kerrick, her BlueFire social worker. AR 252, 2771. In response,
Defendants reversed their position in part, paying benefits for Z.A.’s treatment between August 9,
2018 and September 21, 2018. AR 1145–46. After that date, Defendants denied continued coverage
in a pair of letters dated February 2 and February 8, 2019. AR 1145–46, 1151–52. These letters
were written by two reviewing physicians, Dr. Nelson P. Gruber and Dr. Michael Soto, who
concluded her treatment was no longer medically necessary as of September 22, 2018. Id. Dr.
Gruber concluded continued coverage was not appropriate in part because Z.A.’s condition was
improving, and she “presented no significant, acute behavioral management challenges[,]” “posed
no risk of harm to herself or others[,]” and “had no self harm behaviors[.]” AR 1145–46.
In response, Plaintiffs submitted a second appeal. AR 1118–1784. They included an
additional letter of medical necessity from Melissa Keller Adamson, a social worker at Uinta, and
Z.A.’s treatment records from Uinta, which reflected recent periods of difficulty that led her to be
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placed on suicide watch. AR 1128, 1325–26. On May 2, 2019, Defendants again denied coverage
in a letter by Dr. Sonya Jones. AR 6915. Plaintiffs requested an external review of Defendants’
claim denials. AR 6911–8640. The external reviewer upheld the denial of benefits on medical
necessity grounds. AR 9180–86.
After exhausting the Plan’s prelitigation appeals, Plaintiffs filed this ERISA action on June
4, 2021. ECF No. 2.
II. 	The Court’s Remand Order
In its September 2023 Order, the court found that Defendants arbitrarily and capriciously
denied plan benefits for Z.A.’s treatment at BlueFire and Uinta. ECF No. 65. With respect to Z.A.’s
care at BlueFire, the court found that Defendants’ interpretation of the Plan, which categorizes
wilderness therapy as an unproven treatment, was ambiguous and arbitrarily applied. Id. at 9. The
court also found that Defendants “arbitrarily refused to credit or engage with the opinions of Z.A.’s
medical providers and then failed to sufficiently explain their reasons for denying benefits,
supported by citations to Z.A.’s medical records.” Id. at 10. With respect to Z.A.’s treatment at
Uinta, the court similarly found that Defendants denied the claims without meaningfully evaluating
and responding to the opinions of Z.A.’s medical providers and that their denial letters provided
insufficient explanation. Id. at 17.
Finding remand to be appropriate, the court outlined certain safeguards to govern the
process. Id. at 20. Specifically, Defendants were obligated to conduct their review on remand based
only on rationales that were both raised in the administrative record and communicated to Plaintiffs
prior to the initiation of this litigation. Id.; see David P. v. United Healthcare Ins. Co., 77 F.4th
1293, 1315–16 (10th Cir. 2023) (citing Carlile v. Reliance Standard Life Ins. Co., 988 F.3d 1217,
1229 (10th Cir. 2021)) (“[R]emand . . . does not ‘provide the plan administrator the opportunity to
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reevaluate a claim based on a rationale not raised in the administrative record . . . and not previously
conveyed to Plaintiffs.’”). On remand, Defendants therefore could not rely on any of the post-hoc
reasons for denying benefits that they raised for the first time before this court. ECF No. 65 at 21.
They were obligated to limit their review only to the rationales for denying benefits that they stated
in their denial letters.
In ruling that Defendants were limited to their prelitigation “rationales” on remand, the
court further counseled that “rationales” in this context referred to the specific pieces of evidence
cited in Defendants’ denial letters upon which they denied Plaintiffs’ benefits claims. Id. at 21.
Thus, Defendants could only justify a denial of benefits using the reasons and citations to Z.A.’s
medical records that were included in the prelitigation denial letters—and the denial letters
contained no such citations. Id. at 22. The court acknowledged that this instruction may turn the
remand process into an exercise in futility but reasoned that this was the cost of Defendants’ failure
to meet their obligation to support their decision denying benefits with reasoning and citations to
the record. Id. at 22.
III. 	Post-Remand Redeterminations
On remand, Plaintiffs’ claims went through an additional two rounds of appeal. For both
the BlueFire and Uinta treatment, Defendants again denied the claims.
E. 	Post-Remand Denial — BlueFire
On January 26, 2024, Plaintiffs submitted their first post-remand appeal relating to the
BlueFire treatment. See ECF No. 68-2. Defendants issued a denial letter on February 26, 2024. See
ECF No. 76-1. In denying the claim, the reviewing physician, Dr. Shaley Sehgal, considered
BlueFire medical records, the appeal letters, and relevant court documents, case notes, and
exhibits. Id. at 3. Dr. Sehgal provided detailed summaries of the letters and materials offered by
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Plaintiffs, including the letters of medical necessity written by Dr. LaFollette, Jeanette Higgins,
and Shannon Kerrick. Id. at 4–8. Dr. Sehgal also used the American Association of Community
Psychiatrists CALOCUS-CASII Child and Adolescent Level of Care/Service Intensity Utilization
System for Level 5 (the “CALOCUS-CASII Guidelines”). Id. at 8. Dr. Sehgal reached the
conclusion that, under the CALOCUS-CASII Guidelines, 24-hour care in a mental health
residential treatment center level of care was appropriate. Id. at 10.
However, Dr. Sehgal found that BlueFire did not provide services that met the intensity of
a clinical residential treatment center under the American Academy of Child and Adolescent
Psychiatry Principles of Care for Treatment of Children and Adolescents with Mental Illnesses in
Residential Treatment Centers (the “AACAP Principles”). Id. For example, Dr. Sehgal noted that
the record did not contain any psychiatric or nursing notes, that there is no evidence of a
psychiatrist meeting with Z.A. weekly, that there did not appear to be sufficient family engagement
in the program, and that there was no evidence of a medical assessment taking place within a week
of Z.A. transferring to the facility. Id. at 10–11. Each of these were required under the AACAP
Principles. Id.
On May 17, 2024, Plaintiffs filed their level two post-remand appeal. See ECF No. 68-3.
On July 11, 2024, Defendants issued another denial letter. See ECF No. 68-4. In that letter,
reviewing physician Dr. Theodore Allchin similarly found that the clinical information provided
supported 24-hour care in a residential treatment center but that BlueFire did not provide services
that met the intensity of a clinical residential treatment center. Id. at 6.
F. 	Post-Remand Denial — Uinta
Plaintiffs’ January 26, 2024 post-remand appeal also related to Z.A.’s treatment at Uinta.
See ECF No. 68-2. Defendants issued a denial letter with respect to the Uinta treatment on February
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26, 2024. See ECF No. 76-2. Within the denial letter, reviewing physician Dr. Sherifa Iqbal
outlined various documents that were reviewed and employed both the CALOCUS-CASII
Guidelines and the original Optum Level of Care Guidelines: Mental Health Residential Treatment
Center (the “Optum LOC RTC Guidelines”). See id. at 16. After providing a detailed analysis that
often cited to the medical record, Dr. Iqbal found that the treatment was not medically necessary
as of September 22, 2018, primarily because of certain progress that Z.A. had been making (though
Dr. Iqbal did concede that Z.A. had sporadic issues both leading up to and after September 22). Id.
at 7–11.
On May 17, 2024, Plaintiffs filed their level two post-remand appeal. See ECF No. 68-3.
On July 11, 2024, Defendants issued another denial letter. See ECF No. 68-5. In that letter,
reviewing physician Dr. Theodore Allchin similarly found the treatment not medically necessary.
See id. at 3. Dr. Allchin used the CALOCUS-CASII Guidelines in the analysis. Id. at 8.
IV. 	Current Proceedings
On December 31, 2025, Plaintiffs moved for the case to be re-opened, a request that the
court granted. See ECF Nos. 67, 71. Plaintiffs concurrently filed another motion, entitled a
“Renewed Motion for Benefits, Attorney Fees, Prejudgment Interest, and Costs.” ECF No. 68. In
that motion, Plaintiffs in part argue that Defendants’ post-remand conduct violated the guardrails
the court set out in its prior order and that, consequently, the court should award Plaintiffs full
benefits for the treatment and the other associated fees, interest, and costs. ECF No. 68 at 25.
On March 18, 2026, Defendants filed a motion entitled “Cross Motion for Summary
Judgment.” ECF No. 77. Defendants argue that their post-remand decisions were not arbitrary and
capricious and that the court should grant summary judgment in their favor. ECF No. 77 at 7.
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DISCUSSION
I. 	Cross-Motions for Summary Judgment
As a preliminary matter, the court addresses the procedural posture of the case. To start,
Plaintiffs filed a “Renewed Motion for Benefits, Attorney Fees, Prejudgment Interest, and Costs.”
ECF No. 68. Defendants in turn filed a “Cross-Motion for Summary Judgement.” ECF No. 77.
The posture of Plaintiffs’ motion incorrectly assumes that the court has already ruled that
Defendants’ post-remand denials were improper. The court did indeed grant summary judgment
already, but it then remanded the case back to Defendants to conduct a renewed evaluation. See
ECF No. 65. Now that Defendants have done so, and the case has been re-opened, the court
properly considers whether either party is entitled to summary judgment based on the renewed,
post-remand evaluations. Furthermore, whether or not Defendants adhered to the court’s remand
strictures will be considered in the court’s analysis, but any alleged non-compliance by Defendants
does not automatically shift the procedural posture to a consideration of remedies. See, e.g., Colby
v. Assurant Emp. Benefits, 818 F. Supp. 2d 365, 381–82 (D. Mass. 2011), aff’d sub nom. Colby v.
Union Sec. Ins. Co. & Mgmt. Co. for Merrimack Anesthesia Assocs. Long Term Disability Plan,
705 F.3d 58 (1st Cir. 2013) (factoring an administrator’s disregard of the court’s remand order into
whether the administrator acted arbitrarily and capriciously post-remand).
After all, it is customary in ERISA cases for district courts to review cross-motions for
summary judgment post-remand. See Graham O. v. United Behav. Health, No. 1:18-CV-31-TS,
2024 WL 170739, at *1 (D. Utah Jan. 16, 2024). The court thus treats these two motions as cross-
motions for summary judgment.
A. Standard of Review
Under Federal Rule of Civil Procedure 56(a), “[t]he court shall grant summary judgment
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if the movant shows that there is no genuine dispute as to any material fact and the movant is
entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). However, when both parties move
for summary judgment in an ERISA proceeding focusing on a benefit denial claim, the parties
have effectively “stipulated that no trial is necessary” and thus “summary judgment is merely a
vehicle for deciding the case.” See LaASMAR v. Phelps Dodge Corp. Life, Accidental Death &
Dismemberment & Dependent Life Ins. Plan, 605 F.3d 789, 796 (10th Cir. 2010) (citation omitted).
In these instances, “the factual determination of eligibility for benefits is decided solely on the
administrative record, and the non-moving party is not entitled to the usual inferences in its favor.”
Id. (citation omitted).
When a claim administrator holds discretionary authority to determine benefits eligibility,
a reviewing court applies “a deferential standard of review, asking only whether the denial of
benefits was arbitrary and capricious.” Weber v. GE Grp. Life Assurance Co., 541 F.3d 1002, 1010
(10th Cir. 2008) (citations omitted). An administrator with discretionary authority may delegate its
discretion to a third party, whose denial decisions are then also reviewed under an arbitrary and
capricious standard. Geddes v. United Staffing Alliance Employee Medical Plan, 469 F.3d 919,
926–27 (10th Cir. 2006).
The parties dispute whether this deferential standard of review applies. Defendants argue
that the court should continue to apply it in these post-remand proceedings. ECF No. 75 at 20.
Plaintiffs ask the court to review these post-remand denials de novo. ECF No. 88 at 37. In line with
other courts, the court applies the deferential standard of review. See Torrey v. Qwest Commc’ns
Int’l, Inc., 838 F. Supp. 2d 1201, 1209 (D. Colo. 2012) (applying the arbitrary and capricious
standard post-remand); McMillan v. AT&T Umbrella Benefit Plan No. 1, No. 14-CV-717-GKF-
PJC, 2017 WL 3478482, at *4 (N.D. Okla. Aug. 14, 2017), amended in part, No. 14-CV-717-GKF-
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PJC, 2017 WL 4407935 (N.D. Okla. Oct. 4, 2017), and aff’d, 746 F. App’x 697 (10th Cir. 2018),
and aff’d, 746 F. App’x 697 (10th Cir. 2018) (same).
Claim denials are upheld on arbitrary and capricious review if “reasonable and supported
by substantial evidence.” D. K. v. United Behavioral Health, 67 F.4th 1224, 1235 (10th Cir. 2023)
(citing Adamson v. Unum Life Ins. Co. of Am., 455 F.3d 1209, 1212 (10th Cir. 2006)); see also
David P. v. United Healthcare Ins. Co., 77 F.4th 1293, 1308 (10th Cir. 2023) (quoting Graham v.
Hartford Life & Acc. Ins. Co., 589 F.3d 1345, 1358 (10th Cir. 2009)) (“We define substantial
evidence as ‘such evidence that a reasonable mind might accept as adequate to support the
conclusion reached by the decision-maker. Substantial evidence requires more than a scintilla but
less than a preponderance.’”). A coverage decision lacks substantial evidence if it rejects and fails
to explain why it disagrees with opinions from a plaintiff’s medical providers, D. K., 67 F.4th at
1238–42, if it fails to sufficiently explain its conclusions with supportive reasoning and citations
to the record, id. at 1242–43, or if it “is not grounded [on] any reasonable basis[,]” Flinders v.
Workforce Stabilization Plan of Phillips Petroleum Co., 491 F.3d 1180, 1193 (10th Cir. 2007)
(citations and internal quotation marks omitted), abrogated on other grounds by Metro. Life Ins.
Co. v. Glenn, 554 U.S. 105 (2008).
A coverage decision’s reasonableness is further judged on whether it resulted from a
“reasoned and principled process.” D. K., 67 F.4th at 1236 (quoting Flinders, 491 F.3d at 1193).
To avoid having their claim denials found arbitrary and capricious, ERISA administrators are
obliged to engage in a “full and fair review” of benefits claims and appeals, considering the
insured’s records and sufficiently explaining their decision. See 29 C.F.R § 2560.503-1(h)(2)(iii)–
(iv). “ERISA denial letters play a particular role in ensuring full and fair review[,]” so “[a] district
court [is] correct to focus its review on the denial letters” when evaluating whether an insurer
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conducted a full and fair review. D. K., 67 F.4th at 1239.
To avoid a finding that a denial of benefits was arbitrary and capricious, ERISA
administrators must engage in “reasonable, ‘meaningful dialogue’” in the denial letters they issue.
Id. at 1240. Meaningful dialogue requires denial letters to be “comprehensive and include requests
for additional information, steps claimants may take for further review, and specific reasons for
the denial.” Id. at 1239 (citing 29 C.F.R. § 2560.503-1(f)(3); 29 C.F.R. § 2560.503-1(h)(3), (4)).
In accordance with ERISA’s objective of facilitating meaningful dialogue regarding benefits
denials, courts limit their review of Defendants’ claim denials to the information conveyed to
Plaintiffs in the prelitigation and post-remand claims and appeals process. See Ian C. v.
UnitedHealthcare Ins. Co., 87 F.4th 1207, 1226 (10th Cir. 2023) (“Finally, United insists that its
reviewers’ internal notes are properly a part of the administrative record for Ian C.’s claim. Our
recent disposition in D. K. forecloses this argument. . . . Only the rationales articulated to the
beneficiary in the denial letter are eligible for review[.]”).
B. 	Defendants’ Post-Remand Denials
Plaintiffs argue the post-remand denials were arbitrary and capricious foremost because
Defendants failed to follow the court’s remand guardrails. The court first addresses this argument
before turning to Plaintiffs’ other arguments.
1) 	Defendants’ Compliance with the Court’s Remand Instructions
Plaintiffs’ first argument is that Defendants ignored the court’s remand instructions and that
the court should accordingly award benefits to Plaintiffs. Defendants, for their part, do not contest
that their post-remand denials blatantly ignored the guardrail instructions the court set. See ECF
No. 77 at 19–23. Instead, they argue against those instructions, asserting they go against Tenth
Circuit precedent. See, e.g., id.; see also ECF No. 77 ¶ 25 (Defendants stating that “[t]he Court’s
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safeguards were not immediately appealable because the remand order was not a final order”).
Given this disregard for the court’s order, the court’s decision would seemingly be an easy
one at this stage. After all, court orders cannot be ignored simply because a party disagrees with
them or believes them to be unsound. See Cooper v. Aaron, 358 U.S. 1, 24 (1958) (Frankfurter, J.,
concurring) (“Criticism need not be stilled. Active obstruction or defiance is barred.”); United
States v. Jefferson, 816 F. Supp. 3d 590, 598 (E.D. Va. 2026) (“Simply flouting a judicial order
because of a disagreement of ‘interpretation’ and acting like that order does not exist is simply not
an option.”). Moreover, a failure to abide by a court’s remand order may by itself make any post-
remand decisions arbitrary and capricious. See Colby v. Assurant Emp. Benefits, 818 F. Supp. 2d
365, 384 (D. Mass. 2011) (“In light of USIC’s failure to abide by, as well as its continued resistance
to, the Order in Colby I, this Court now awards Dr. Colby retroactive LTD benefits . . . .”);
Aisenberg v. Reliance Standard Life Ins. Co., 718 F. Supp. 3d 480, 490 (E.D. Va. 2024) (“As a
general rule, on the remand of a case after appeal, the agency from which appeal is taken must
comply with the mandate of the court and obey the directions therein without deviation. . . . This
directive, which applies full-well to Defendant, was not followed. . . . [D]isregarding the Court’s
directives may — standing alone — amount to an abuse of discretion . . . .”).
What makes Defendants’ post-remand actions all the more striking is that they had other
options they could have pursued. For example, they could have followed in good faith the remand
process the court set out and appealed any final decision. If they wanted more immediate relief,
they could have simply moved for the court to reconsider its prior order. See Fed. R. Civ. P. 54(b);
Romero v. Core Civic, Inc., No. 1:21-CV-544 KG/KRS, 2022 WL 17360324, at *2 (D.N.M. Dec.
1, 2022) (“Reconsideration of an interlocutory order is a matter of the Court’s discretion . . . .”).
The court is hard pressed to understand Defendants’ actions up to this point and is well within its
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discretion to base its holding on this non-compliance alone.
Nevertheless, upon further reviewing the relevant case law, the court finds that its initial
remand instructions were too restrictive—a decision, it is worth emphasizing again, that could
have been reached upon a motion for reconsideration. In the court’s prior order, the court grappled
with two then-recent Tenth Circuit decisions. See M.A. behalf of Z.A. v. United Healthcare Ins.,
No. 1:21-CV-00083-JNP-DBP, 2023 WL 6318091, at *10–*11 (D. Utah Sept. 28, 2023). First, in
May 2023, the Tenth Circuit ruled in D. K. v. United Behav. Health, 67 F.4th 1224 (10th Cir. 2023),
cert. denied, 144 S. Ct. 808 (2024). The panel held that a court can award benefits and forego
remand “when the record shows that benefits should clearly have been awarded by the
administrator” or “if a plan administrator’s actions were clearly arbitrary and capricious.” Id. at
1243. Ultimately, the panel held that “[c]onsidering the administrator’s clear and repeated
procedural errors in denying this claim, it would be contrary to ERISA fiduciary principles to
mandate a remand and provide an additional ‘bite at the apple.’” Id. at 1244.
But just a few months later, in August 2023, the Tenth Circuit reversed this court’s award
of benefits that had been based on procedural errors in David P. v. United Healthcare Ins. Co., 77
F.4th 1293 (10th Cir. 2023). This panel stated that, “[g]enerally, ‘[r]emand is appropriate if the
administrator failed to make adequate factual findings or failed to adequately explain the grounds
for the decision.’ . . . ‘But if the evidence in the record clearly shows that the claimant is entitled
to benefits, an order awarding such benefits is appropriate.’” Id. at 1315 (citation modified).
Because the panel found that United failed to consider all of the evidence, failed to adequately
explain its decision, and failed to engage with the plaintiffs, the court decided remand was proper
for further consideration. Id. Though citing to D. K. at various points within the ruling, the panel
did not engage with D. K.’s award of benefits within its remand analysis.
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What remains unclear, then, is whether the Tenth Circuit has adopted a procedural basis for
awarding benefits (where the administrator has acted arbitrarily and capriciously by committing
clear and repeated procedural errors), in addition to its clearly recognized substantive basis for
awarding benefits (when the record is clear they are due). And if a procedural basis has been
adopted, as suggested by the Tenth Circuit’s ruling in D. K., it remains unclear what level of
procedural violations warrant an award of benefits.
District courts in this circuit have accordingly varied in their approach to these two cases,
with some adopting the procedural basis and others not. Contrast IAN C v. United Healthcare Ins.,
No. 2:19-CV-474-HCN, 2024 WL 3415890, at *2 (D. Utah July 15, 2024) (“Additionally, in very
limited circumstances, a court can award benefits if a plan administrator engaged in ‘clear and
repeated procedural errors’ when denying a claim.”), and S.K. v. United Behav. Health, No. 2:18-
CV-880-RJS-DBP, 2023 WL 7221013, at *34 (D. Utah Sept. 29, 2023) (“Benefits may also be
awarded if an administrator’s actions ‘were clearly arbitrary and capricious,’ or if remand would
simply be an ‘opportunity to retool a defective system,’ or give ‘an additional ‘bite at the apple’ to
ERISA administrators acting unjustly.’”) (citation modified), with S.B. v. Blue Cross Blue Shield
of Illinois, No. 2:22-CV-336-AMA, 2025 WL 327920, at *13 (D. Utah Jan. 29, 2025) (“Upon a
finding that BCBS acted arbitrarily and capriciously two remedies are available: remand or an
award of benefits. Under Tenth Circuit precedent remand is the default unless the court determines
that the record clearly shows that the plaintiff is entitled to benefits. See David P., 77 F4th at 1315–
16. But that default usually arises in the context of a denial based upon medical necessity—an
issue not presented here.”).
Animating much of this divergence in approach is a concern that the remand process
provides an additional “‘bite at the apple’ to ERISA administrators acting unjustly,” at a significant
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cost to plan claimants. See S.K., No. 2:18-CV-880-RJS-DBP, 2023 WL 7221013, at *34 (quoting
D. K., 67 F.4th at 1243). Indeed, courts have long been skeptical of plan administrators devising
and deploying post-hoc arguments and rationales in litigation to “shore up” claim denials. Univ.
Hosps. of Cleveland v. Emerson Elec. Co., 202 F.3d 839, 848 n.7 (6th Cir. 2000); see Halpin v.
W.W. Grainger, Inc., 962 F.2d 685, 696 (7th Cir. 1992) (stating ERISA and its regulations “were
not intended to be used . . . as a smoke screen”); Spradley v. Owens-Illinois Hourly Emps. Welfare
Ben. Plan, 686 F.3d 1135, 1140 (10th Cir. 2012) (“[W]e will not permit ERISA claimants denied
the timely and specific explanation to which the law entitles them to be sandbagged by after-the-
fact plan interpretations devised for purposes of litigation.”). Yet, the remand process and the
additional “bite” that it provides appears to enable much of the same behavior.
Fundamentally, ERISA mandates that Plan administrators provide claimants with a “full
and fair review.” 29 U.S.C. § 1133(2). Nevertheless, in many cases, United Healthcare and other
claim administrators appear to be reviewing claims in a less than full and seemingly unfair manner.
See Dwyer v. United Healthcare Ins. Co., 115 F.4th 640, 650 (5th Cir. 2024) (“We therefore join a
growing number of decisions rejecting similar denial letters issued by United across the country.”).
Plan claimants who pursue already costly litigation then face an additional burden at the remand
stage: having to rebuff denial rationales that should have been available to them often years prior
when their ability to marshal contrary evidence from contemporaneous medical provider opinions
was still fresh.
The court is sympathetic to Plaintiffs’ argument that the current remand process appears to
incentivize plan administrators to provide cursory, violative denial letters that simply state the
treatment was not medically necessary. See ECF No. 68 at 23. Few claimants have the resources
or ability to pursue litigation, and even when facing review by a court, the plan administrators are
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then able to rectify their procedural violations on remand, facing a hamstrung claimant.
These process considerations inform how courts structure remand orders. Upon remand,
courts often order that administrators must review claims for “further, and proper, consideration.”
David P., 77 F.4th at 1315. Courts also restrict the remand analysis, generally barring consideration
of new rationales not raised in the administrative record. See id. (“Our remand, however, does not
‘provide the plan administrator the opportunity to reevaluate a claim based on a rationale not raised
in the administrative record,’ . . . and not previously conveyed to Plaintiffs.”) (internal citations
removed).
In its prior order, the court construed its limit on raising new rationales to include a limit
on citing to evidence not previously cited. In certain contexts, this additional restriction would help
to tailor the remand process to focus solely on the substantive arguments previously conveyed to
claimants. In this case, however, the restriction encumbered Defendants’ ability to conduct a proper
review of the claims, most prominently because Defendants completely failed to cite to the record
in their initial denials. Because remand instructions should encourage attention to the substantive
issues without unduly constraining the process, the court will not enforce its previously stated limit
on citations to the record when reviewing Defendants’ post-remand denials. But the court continues
to adhere to the limit on new rationales, which the Tenth Circuit has endorsed. See id.
2) 	Defendants’ Post-Remand Denials Were Not Arbitrary and Capricious
Reviewing Defendants’ post-remand denials under the arbitrary and capricious standard,
the court finds that the post-remand denials were “reasonable and supported by substantial
evidence.” See D. K., 67 F.4th at 1235 (citing Adamson, 455 F.3d at 1212).
Plaintiffs raise numerous arguments, including that (1) Defendants improperly based the
post-remand denials on new or prohibited rationales, and (2) the record supports that Z.A.’s
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treatment was medically necessary.
The court first considers whether Defendant’s post-remand rationales were new or
prohibited by the court’s prior order. At the outset, the court notes that the line between a new
rationale and an elaboration or refinement of a previous rationale is sometimes murky and often
context dependent. This line becomes murkier due to the iterative opportunities defendants get to
“clarify” their rationales in the remand process. Policing this boundary can therefore be difficult.
As a prime example, in its prior order, the court restricted Defendants to rationales that
they previously raised and communicated to Plaintiffs in the pre-litigation process. For the
BlueFire treatment, the rationales that the pre-litigation denial letters did convey (though, at the
time, arbitrarily and capriciously) were: (1) under the wilderness therapy Policy, the treatment was
not covered, (2) under the Optum LOC RTC Guidelines, the treatment was not medically
necessary, and (3) BlueFire did not provide the scope or intensity of services that would meet the
definition of a clinical residential treatment center. See ECF No. 65 at 15; AR 1813–14; AR 4786–
87; AR 9150–52; AR 9175–79.
The court also stated that Defendants could not rely on certain rationales that they had only
raised once litigation started. “These post-hoc rationales include, but may not be limited to the
following: (1) that BlueFire provided mere custodial supervision for Z.A. or that Z.A. simply
remained at BlueFire out of convenience; (2) that BlueFire couldn’t provide RTC-level care
because it failed to conduct a psychiatric evaluation within 24 hours of Z.A.’s arrival or schedule
weekly therapy with a psychiatrist; and (3) that Plaintiffs failed to obtain preauthorization before
receiving care at BlueFire, an out-of-network provider.” ECF No. 65 at 21 n.4.
The first and third of these listed post-hoc rationales were clearly new and separate
arguments that had not been raised to Plaintiffs in the pre-litigation process. But the second
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rationale—that BlueFire could not provide RTC-level care because it did not conduct a psychiatric
evaluation within 24 hours or schedule weekly psychiatric therapy—presented a closer call. The
court now reconsiders its prior analysis and finds that this argument was not an entirely new post-
hoc rationale. Rather, it was an elaboration of Defendants’ existing argument that BlueFire did not
provide the scope or intensity of services that would meet the definition of a clinical residential
treatment center.
In this context, this distinction matters. Before the court ordered a remand, Plaintiffs were
faced with constantly evolving rationales, turning the appeals process into a game of whack-a-
mole. Defendants continued to play that game into the litigation process, providing an eleventh-
hour explanation for why BlueFire did not provide the necessary services to be considered a
residential treatment center. That eleventh-hour explanation rendered the denial of benefits
arbitrary and capricious because it was untimely and indicative of a lack of meaningful dialogue
between the parties.
But Defendants’ renewed elaboration on this argument now does not present the same
issues. Post-remand, Defendants were obliged by the ERISA process to further elaborate and
explain any continued denials based on the broader argument that BlueFire did not provide the
necessary services, and they did so. And though their compliance comes unfortunately late and
only due to court intervention, Plaintiffs now have had the opportunity for meaningful dialogue
with Defendants. Accordingly, Defendants’ argument that BlueFire did not provide the necessary
services to be considered a residential treatment center—and the supportive explanatory
reasoning—were valid arguments for Defendants to make post-remand.
Plaintiffs respond, however, that Defendants had never cited to the AACAP Principles in
the pre-litigation process. Plaintiffs argue that the use of these specific Principles is tantamount to
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employing a new rationale.
The court agrees that, at times, the use of new analytical guidelines does violate the ERISA
process by rising to the level of being a new denial rationale. The court has found so before. See
Anne A. v. United Healthcare Ins. Co., No. 2:20-CV-00814-JNP, 2026 WL 811540, at *13 (D. Utah
Mar. 24, 2026). But the court has never expressed this as a per se rule. For example, in D.B. v.
United Healthcare Insurance, the court found the use of a new analytical framework to be violative
when Defendants introduced the new framework “in the very last post-remand denial letter,
depriving Plaintiff of any opportunity to tailor her arguments to the newly relevant framework.”
No. 1:21-CV-00098-JNP-CMR, 2026 WL 851250, at *10 (D. Utah Mar. 27, 2026). The court noted
that “claimants often explicitly rely on the relevant guidelines used by plan administrators when
crafting their arguments in the pre-litigation and litigation process.” Id. at *9. Thus, “allowing a
plan administrator to justify a denial on new guidelines after consistently relying on a different set
of guidelines for years would disadvantage claimants, potentially allowing administrators
‘interminable opportunities to search for alternative grounds to deny benefits.’” Id. (quoting
Spradley v. Owens-Illinois Hourly Emps. Welfare Ben. Plan, 686 F.3d 1135, 1142 (10th Cir. 2012)).
Similarly, in Anne A., the court found fault with Defendants using the CALOCUS-CASII
Guidelines post-remand when they had only used the Optum LOC RTC Guidelines pre-remand.
See Anne A., No. 2:20-CV-00814-JNP, 2026 WL 811540, at *13.
Here, the AACAP Principles were introduced in a different context. In the pre-litigation
process, Defendants argued that BlueFire did not provide the required services to be considered a
residential treatment center, but they did not elaborate on how they came to that decision. Now,
they attempt to do so using the AACAP Principles. Unlike in Anne A., they are not switching from
one analytical framework to another. And unlike in D.B., Plaintiffs had the opportunity to engage
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with the AACAP Principles in the second level of post-remand review. Furthermore, the AACAP
Principles are not employed in the same way as the CALOCUS-CASII or Optum LOC RTC
Guidelines. While all provide evaluative criteria to some degree, the CALOCUS-CASII and
Optum Guidelines are more formal, standardized assessment instruments. For all these reasons,
the court does not find Defendants’ reference to the AACAP Principles as raising a new rationale.
For the Uinta treatment, the rationale that the pre-litigation denial letters conveyed was that
Z.A. made progress during her treatment, so the treatment was no longer medically necessary as
of September 22, 2018 under the Optum LOC RTC Guidelines. ECF No. 65 at 6; AR 195; AR
6913–15; AR 9180–86; see ECF No. 77 at 9 (Defendants conceding that they used the Optum LOC
RTC Guidelines in the pre-litigation process). As of 2020, Defendants retired those guidelines in
favor of the CALOCUS-CASII Guidelines. ECF No. 77 at 9. Plaintiffs allege that the use of the
CALOCUS-CASII Guidelines post-remand violated the court’s prior order to not invoke new
rationales.
Consistent with the court’s prior orders, the court finds Defendants’ use of the CALOCUS-
CASII Guidelines in the first remand letter to be a new rationale. But as in Anne. A., the court’s
exclusion of this rationale has a limited effect. See Anne A., No. 2:20-CV-00814-JNP, 2026 WL
811540, at *13. Here, the first denial letter also employed the Optum LOC RTC Guidelines.1F
2 While
the second and final denial letter only used the CALOCUS-CASII Guidelines, Plaintiffs by then
had the opportunity to engage with the new analytical framework. See ECF No. 68-3 at 79–138.
2 Plaintiffs also argue that Defendants should not be able to use the Optum RTC LOC Guidelines
because another district court enjoined United from using those guidelines. ECF No. 88 at 46. But
Plaintiffs also note that the specific guidelines Defendants used here differ to at least some degree
from the ones that were enjoined. Id. In addition, the post-remand denial letters were issued before
any injunction was entered.
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Indeed, 	and 	importantly, 	Plaintiffs 	agreed 	that 	the 	CALOCUS-CASII 	Guidelines 	would
“appropriately” evaluate Z.A.’s condition in their second-level post-remand appeal. ECF No. 68-
3 at 79. Plaintiffs accordingly made extensive arguments within the CALOCUS-CASII framework
in their second-level appeal, requiring the final reviewer to engage with the same framework when
responding.
Having resolved the permissible scope of Defendants’ post-remand reasoning, the court
turns to the actual denial of benefits—based on sufficiency of services for BlueFire and on medical
necessity for Uinta. With respect to BlueFire, Plaintiffs do not argue anything additional beyond
their contention that Defendants’ reliance of the AACAP Principles was improper, which the court
has already addressed. With respect to Uinta, Plaintiffs argue that the treatment was medically
necessary after September 21, 2018. See ECF No. 88 at 38.
Despite Plaintiffs’ arguments, Defendants’ post-remand denial letters “[were] predicated
on a reasoned basis.” Ellis v. Liberty Life Assurance Co., 958 F.3d 1271, 1290 (10th Cir. 2020)
(quoting Adamson, 455 F.3d at 1212). The letters explained their conclusions, cited to the record,
and addressed Plaintiffs’ arguments, including the letters of necessity that Plaintiffs provided. See
ECF No. 68-5 at 8. Ultimately, the reviewers found that by September 22, 2018, Z.A.’s “ongoing
symptoms had decreased in intensity and could now be safely managed in a lower level of care.”
ECF No. 76-2 at 9. The court is unable to conclude that these reasons, which were clearly
articulated and addressed Plaintiffs’ arguments and evidence, were not reasonable. The court thus
has no basis to find Defendants’ post-remand denials to be arbitrary and capricious.
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II. 	Attorney’s Fees
The court finally turns to Plaintiffs’ motion for attorney’s fees.2F
3 As the Tenth Circuit has
described, “ERISA contains a limited fee-shifting provision in § 1132(g). In relevant part, it states:
‘[i]n any action under this subchapter . . . by a participant, beneficiary, or fiduciary, the court in its
discretion may allow a reasonable attorney’s fee and costs of action to either party.’” Stark v.
Reliance Standard Life Ins. Co., 142 F.4th 1252, 1258 (10th Cir. 2025). “‘A fee claimant need not
be a prevailing party to be eligible for an award of attorney’s fees and costs under ERISA.’ Instead,
a district court has the discretion to award fees ‘as long as the fee claimant has achieved some
degree of success on the merits.’” Lightfoot v. Principal Life Ins. Co., 547 F. App’x 864, 866 (10th
Cir. 2013) (unpublished) (citation modified).
District courts may consider five factors in exercising their discretion: “(1) the degree of
the opposing party’s culpability or bad faith; (2) the opposing party’s ability to satisfy an award of
fees; (3) whether an award of fees would deter others from acting under similar circumstances; (4)
whether the party requesting fees sought to benefit all participants and beneficiaries of an ERISA
plan or resolve a significant legal question regarding ERISA; and (5) the relative merits of the
parties’ positions.” Id. But the Tenth Circuit has also ruled that “under § 1132(g), attorney’s fees
are unavailable for pre-litigation administrative proceedings.” Stark, 142 F.4th at 1258.
The court exercises its discretion to award attorney’s fees to Plaintiffs for both the pre-
remand and post-remand litigation. Here, Plaintiffs initially prevailed on summary judgment,
achieving success on the merits based on Defendants’ refusal to engage in meaningful dialogue
3 Plaintiffs’ motion for summary judgment (entitled a “Renewed Motion for Benefits, Attorney
Fees, Prejudgment Interest, and Costs”) also contains a request for an award of fees, interest, and
costs.
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and a full and fair review with Plaintiffs as required by ERISA. The current proceedings continue
to reflect that procedural history, required only because of Defendants’ prior arbitrary and
capricious conduct. The court also finds that an award of attorney’s fees would serve an important
deterrence function with respect to the ERISA process. Requiring plan administrators to pay
attorney’s fees after engaging in violations of the ERISA process, even when later rectifying those
issues post-remand, will incentivize plan administrators to engage in a full and fair review in the
first instance.
The court therefore GRANTS Defendants’ motion for summary judgment and DENIES IN
PART Plaintiffs’ motion.
CONCLUSION
For the above reasons, the court hereby ORDERS:
1. 	Defendants’ motion for summary judgment is GRANTED. ECF No. 77.
2. 	Plaintiffs’ “Renewed Motion for Benefits, Attorney Fees, Prejudgment Interest, and Costs”
is DENIED in part and GRANTED in part. ECF No. 68. Plaintiffs are not awarded benefits
but are awarded attorney’s fees and costs. Plaintiffs may submit their claim for fees and
costs in a separate motion, which should include a fee affidavit.
Signed August 20, 2026.
BY THE COURT
______________________________
Jill N. Parrish
United States Chief District Judge
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