In
Jessica U. v. Health Care Service Corp., a Montana district court held that an ERISA plan administrator improperly denied benefits for mental health residential treatment based solely on so-called Milliman Care Guidelines that were not included in the plan documents.
The Milliman Care Guidelines ( MCG ) are a set of health industry best practices, guidelines and diagnostic criteria published by MCG Health for providers and health plans. Although the MCG are widely used by health care professionals, the
Jessica U. case illustrates that plan administrators must use caution when relying on the guidelines, or other materials outside of the plan, as grounds to deny health benefits.