Suzanne Bynum v. Cigna Healthcare of North Carolina

Suzanne Bynum initiated this ERISA civil action in the District of
South Carolina against CIGNA Healthcare of North Carolina, Incorporated ("CIGNA"), maintaining that CIGNA had improperly denied
her infant daughter's claim for health benefits for treatment of a skull
deformity. The district court reversed CIGNA's decision and awarded
the benefits sought by Ms. Bynum's daughter. CIGNA has appealed
the court's ruling, maintaining that its denial of benefits was appropriate. As explained below, we agree that Ms. Bynum's infant daughter,
Katrina, was entitled to coverage from CIGNA for treatment of her
misshapen head, and we affirm.

I.

A.

Katrina Bynum, along with her twin sister, was born to Ms. Bynum
in late 1999 by spontaneous vaginal delivery after a thirty-nine week
gestation period. At her birth, Katrina exhibited symptoms of congenital torticollis, i.e., a severely twisted neck,1 which subsequently
resulted in plagiocephaly, i.e., an abnormally asymmetrical head.2 In
May 2000, concerned about her nine-month old daughter's medical
condition and desiring to obtain treatment for it, Ms. Bynum soughtmedical care for Katrina from a pediatrician in Matthews, North Carolina. This pediatrician, Dr. Michelle Parish, referred Katrina to a specialist in neurosurgery, and, at the direction of Dr. C. Scott
McLanahan, a pediatric neurosurgeon practicing in Charlotte, North
Carolina, Katrina's condition was treated with a medical procedure
known as "cranial banding" or "dynamic orthotic cranioplasty" (the
"DOC Procedure").

The DOC Procedure, which costs approximately $3,000, involved
creating a custom-molded orthotic device to be worn by Katrina in
order to progressively mold and correct the shape of her cranium.3
The purpose of the DOC Procedure, as described by Dr. McLanahan,
was to treat immediately the functional significance of Katrina's
asymmetrical skull because "head shape abnormalities or asymmetry
of the skull base can lead to further deformities or physical impairments of the facial region, such as malocclusion of the mandible."4

B.

In May 2000, Dr. McLanahan submitted to CIGNA a coverage
request for the DOC Procedure utilized to treat Katrina's condition
("Katrina's Claim"). Katrina was an insured of CIGNA through insurance coverage provided to her mother, an employee of an entity called
Pathways for Learning in Charlotte, North Carolina. Ms. Bynum possessed health insurance through her employer-sponsored health plan,
and her family's coverage is governed by the Employee Retirement
Income Security Act (ERISA), 29 U.S.C. S 1001 et seq. CIGNA
serves the plan in two capacities: first, as its insurer, and second, as
its plan administrator. The member certificate (the "Plan") provided
to each of the Plan's insureds describes the insurance coverage and
benefits provided by CIGNA, and it also spells out the administrative
procedures under which the Plan operates. The Plan has established
a two-level administrative appeal and grievance process for the reso-
lution of claims and benefits questions, and it has granted CIGNA the
"final power and discretionary authority to interpret and administer
th[e] Member Certificate, including the authority to make eligibility
determinations."

Katrina's Claim was filed with CIGNA on May 16, 2000, and the
next day one of CIGNA's Medical Directors wrote Ms. Bynum a
denial letter, advising, after "careful review," that CIGNA had "deter-
mined that coverage is not available . . . because cosmetic services are
not covered." CIGNA's denial letter offered no explanation of what
constituted a cosmetic service, and the Plan contains no definition for
either the terms "cosmetic" or "cosmetic services."

Thereafter, pursuant to the procedures established in the Plan, Dr.
McLanahan filed with CIGNA, on behalf of Ms. Bynum and Katrina,
what the Plan denominates as a first-level appeal. In this first-level
appeal, CIGNA was requested to review and reconsider its earlier
decision to deny Katrina's Claim for the DOC Procedure.5 By letter
of May 26, 2000, Dr. McLanahan explained to CIGNA that children
suffering from nonsynostoic cranial asymmetries (such as that affect-
ing Katrina) benefit from DOC treatment. He also sought to directly
address the "cosmetic services" issue raised in the denial letter, and
he further advised CIGNA that "[c]orrection of [Katrina's] defect may
in fact lead to a more pleasant appearance, however, it is the functional significan[ce] of the defect that compels the treatment."
(emphasis added). In so concluding, he advised CIGNA, referring to
the DOC Procedure, that "[i]t is clearly not treatment of a cosmetic
deformity." (emphasis added).

CIGNA responded to Katrina's first-level appeal by advising Ms.
Bynum that it was denying coverage for Katrina's Claim. In explaining its decision, CIGNA again maintained that use of the DOC Procedure for nonsynostoic plagiocephaly is a "cosmetic procedure," and
it also asserted that "[t]he documentation fails to substantiate the medical necessity for the [DOC] service." As in its initial denial of
Katrina's Claim, CIGNA offered no definition of what constituted a
"cosmetic procedure" under the Plan.

Thereafter, Ms. Bynum retained counsel on Katrina's behalf, and,
on July 25, 2000, she filed a second-level appeal with CIGNA.
CIGNA then requested production of additional materials or statements that Ms. Bynum deemed relevant to Katrina's Claim, and it
advised Ms. Bynum that her second-level appeal would be heard and
considered by CIGNA's Grievance Committee (the "Committee" or
"CIGNA's Committee").6

On August 30, 2000, Ms. Bynum provided CIGNA's Committee
with additional materials in support of Katrina's Claim. First, she sub-
mitted an affidavit from Dr. McLanahan in which he reiterated that
Katrina "suffers from a head shape abnormality related to intrauterine
molding and postnatal position" and that, in the opinion of a number
of plastic surgeons, "head shape abnormalities or asymmetry of the
skull base can lead to further deformities or physical impairments of
the facial region, such as malocclusion of the mandible." Dr. McLanahan explained that the "true intent" of Katrina's DOC Procedure was
to "eliminate physical defects that might be associated with head
shape abnormalities such as `malocclusion of the mandible,'" and he
concluded that "to a reasonable degree of medical certainty, . . . the
DOC band, as used upon Katrina Bynum, was medically indicated
and was not cosmetic under the terms of the [P]lan."7

Second, Ms. Bynum provided CIGNA's Committee with a letter of
May 25, 2000, from Katrina's treating pediatrician, Dr. Parish. Dr.
Parish explained that Katrina suffered from congenital torticollis that
had been present at birth. Dr. Parish also advised CIGNA that she had
referred Katrina to a neurosurgeon who noted that Katrina had "flattening of the right side of her head, right anterior ear shift, frontal
bossing right greater than left, [and] plagiocephaly." In conclusion,
Dr. Parish related "I believe [Katrina's] plagiocephaly is directly
related to her congenital torticollis . . . [and] therefore is a medical
condition not a cosmetic condition."8

Third, Ms. Bynum submitted to CIGNA's Committee a medical
article discussing the treatment of craniofacial asymmetry with the
DOC Procedure. Fourth, she provided CIGNA's Committee with a
copy of Resolution 119 of the American Medical Association House
of Delegates, which defines reconstructive surgery. Pursuant to the
AMA Resolution, reconstructive surgery is surgery that is "performed
on abnormal structures of the body, caused by congenital defects,
developmental abnormalities, . . . or disease. It is generally performed
to improve function, but may also be done to approximate a normal
appearance." Finally, Ms. Bynum provided the Committee with an
American Orthotic and Prosthetic Association Newsletter showing
that the DOC Procedure had gained FDA approval as an "approved
orthoses" for Katrina's condition.9

On August 30, 2000, the Committee convened to consider
Katrina's Claim. CIGNA representatives were present at the Committee's meeting, but Ms. Bynum and her attorney, though invited, did
not attend.10 CIGNA's Committee then reviewed Katrina's Claim, the
information submitted to it by Ms. Bynum, and a so-called TEC
Assessment Report concerning the DOC Procedure submitted to it by
CIGNA.11 By letter to Ms. Bynum of the following day, CIGNA
advised that its Committee had "decided to uphold the original deci-
sion to deny the Cranial Banding Device." This denial letter explained
that the Committee's decision was based on the "Section 5.0 (letter
M) Exclusion, [wherein] All Cosmetic procedures or surgery are considered non-covered. The documentation received fails to substantiate
the medical necessity for the service."12 This letter, like the earlier
ones, made no effort to explain what CIGNA believed to constitute
"cosmetic" procedures or surgery.

C.

After exhausting her appeal rights under the Plan, Ms. Bynum, on
September 22, 2000, filed suit against CIGNA pursuant to 29 U.S.C.
S 1132(a).13 She alleged, inter alia, that the Plan provided coverage
for the DOC Procedure, and she sought to have the court direct
CIGNA to provide coverage for Katrina's Claim.

On April 12, 2001, with cross motions for summary judgment
pending, the parties appeared before the district court. For whatever
reasons, both parties then requested the court to dispense with the
summary judgment proceedings and to try the case on its merits. With
the consent of the parties, the court then proceeded to handle the case
as a bench trial.14 On May 9, 2001, the court ruled on the merits of
the case, and it determined that the Plan provided coverage for
Katrina's Claim. Bynum v. CIGNA Healthcare of North Carolina,
Inc., Order, C/A No.: 6:00-3009-13 at 14-16 (D.S.C. May 11, 2001)
(the "Opinion"). The court then ordered CIGNA to provide coverage
to Katrina for the benefits sought. Id. at 15-16.

On May 16, 2001, CIGNA filed a timely notice of appeal. We pos-
sess jurisdiction pursuant to 28 U.S.C. S 1291.

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Click the case caption above for the full text of the Court's opinion.

Affirmed

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Unavailable

None