United States Court of Appeals For the First Circuit No. 17-2078 JANE DOE, Plaintiff, Appellant, v. HARVARD PILGRIM HEALTH CARE, INC.; HARVARD PILGRIM PPO PLAN MASSACHUSETTS, GROUP POLICY NUMBER 0588660000, Defendants, Appellees. APPEAL FROM THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MASSACHUSETTS [Hon. Denise J. Casper, U.S. District Judge] Before Thompson, Selya, and Kayatta, Circuit Judges. Mala M. Rafik, with whom Sarah E. Burns and Rosenfeld & Rafik, P.C. were on brief, for appellant. Peter S. Sessions, Lisa S. Kantor, and Kantor & Kantor LLP, on brief for National Alliance on Mental Illness, amicus curiae. Jonathan M. Feigenbaum on brief for United Policyholders and Health Law Advocates, Inc., amici curiae. Christine Zaleski, with whom Steven L. Schreckinger and Anderson & Kreiger LLP were on brief, for appellees. September 6, 2018 KAYATTA, Circuit Judge. Jane Doe's insurer, Harvard Pilgrim Health Care ("HPHC"), deemed part of the time Doe spent at a mental health residential treatment facility not medically necessary under the health care benefits plan established by the employer of Doe's parent. HPHC therefore denied coverage for that portion of the treatment. After several unsuccessful administrative appeals, Doe sued HPHC in federal court under the Employee Retirement Income Security Act ("ERISA"). 29 U.S.C. §§ 1001–1461. On de novo review, the district court agreed with HPHC's determination that continued residential treatment was not medically necessary for Doe. We conclude that the administrative record upon which the district court based its finding should have been supplemented. We therefore reverse in part, vacate in part, and remand for further proceedings. I. A. The following facts are undisputed. On January 17, 2013, Doe was admitted to the Austen Riggs Center ("Riggs") in Stockbridge, Massachusetts for residential mental health treatment. She was experiencing psychosis, suicidal ideation, depression, and anxiety. At the time, Doe was insured under her father's employer-provided HPHC plan (the "Plan"). HPHC contracted with another insurance company, United Behavioral - 2 - Health ("UBH"), to manage mental health services. In order for services to be eligible for coverage under the Plan, they must be, among other things, "medically necessary," a standard defined in the Plan with a degree of detail that is not relevant to what we ultimately decide on this appeal. HPHC approved coverage for an initial residential stay at Riggs. But on February 5, 2013, HPHC, acting through UBH, informed Doe by letter that it would not cover additional time spent at Riggs because further residential treatment was not medically necessary. As UBH explained in the letter, it based this denial on the assessment of UBH's Associate Medical Director, Dr. James Feussner. The letter informed Doe that she had the right to appeal the denial of benefits to UBH/HPHC, on a standard or expedited basis, and that she might also be eligible for an external appeal. Doe requested an expedited appeal. Pursuant to the Plan, HPHC continued to cover Doe's residential treatment through the completion of the internal appeal process. On February 12, 2013, HPHC denied Doe's appeal and upheld ...
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