A.Z. ex rel. Juno Therapeutics, Inc. v. Blueshield
A.Z. ex rel. Juno Therapeutics, Inc. v. Blueshield
Opinion of the Court
THIS MATTER comes before the Court on the defendants' Motion to Dismiss, docket no. 40 (the "Motion").
Background
I. Introduction
Plaintiff A.Z. ("A.Z.") is a 16-year-old female who was diagnosed with depression. Amended Complaint at ¶¶ 5, 17. Following her doctors' recommendation, she attended an outdoor residential mental health program in Oregon. Id. at ¶ 19. She sought reimbursement for the costs of the program under her parents' health benefit plan, but was denied. A.Z., by and through her parents and guardians and on behalf of the Juno Therapeutics, Inc. Health Benefit Plan (the "Plan"),
Regence underwrote, insured, and administered the Plan's health benefits until January 1, 2017. Amended Complaint at ¶ 7. A.Z. is a beneficiary of the Plan whose coverage is through her parent's employment with Juno Therapeutics, Inc. Id. at ¶ 5. A.Z.'s depression reached a level that "required treatment at a licensed outdoor/wilderness behavioral healthcare program." Id. at ¶¶ 17-18. Her doctors recommended that she receive behavioral health treatment at "Evoke, an outdoor residential mental health program in Oregon." Id. at ¶ 19.
II. A.Z.'s Requested Coverage
A.Z. sought preauthorization from Regence for the Evoke treatment, but Regence denied her request. Id. at ¶¶ 29-30. Regence explained that A.Z.'s participation in a wilderness program was not subject to preauthorization or eligible for benefits because it was excluded from the Plan. Id. at ¶ 30, Ex. C. Unable to delay her treatment, A.Z. began the Evoke wilderness program and appealed Regence's denial of coverage. Id. at ¶¶ 34, 38. Regence denied the appeal, reaffirming that the Plan does not cover the requested services and "specifically excludes wilderness therapy programs from coverage." Id. at ¶¶ 35, 39. By the time she completed her treatment at Evoke, A.Z. had incurred nearly $50,000 in expenses, which Regence refused to reimburse. See Amended Complaint, Exhibit 11 (periodic statements submitted by Evoke).
III. The Evoke Wilderness Program
The State of Oregon licenses Evoke as an "outdoor youth program." Id. at ¶ 20, Exhibit B ("Certificate of Approval to Operate a Child Caring Agency"). Evoke's licensing certificate confirms that it is authorized to operate its program "under provisions of *1073Oregon Revised Statutes 418.205 to 418.327 and related statutes ...." Id. , Exhibit B. Because it is a certified "outdoor youth program," Evoke is authorized by statute to provide, in an outdoor living setting, services to children who have mental health problems. Id.
Consistent with its statutory authority, Evoke's wilderness program "is a personal intervention that utilizes nature, small-group outdoor living, backpacking, one-on-one therapy, and group therapy." Evoke Therapy Programs, Wilderness Therapy (March 2017), https://evoketherapy.com/assets/Uploads/Wilderness-Therapy-3-17.pdf. Among other services, Evoke's wilderness program provides therapy from "experienced Master's or Ph.D. level therapists" who "create customized treatment plans for each participant and their families and offer guidance and support to meet their unique challenges." Id.
IV. A.Z.'s Claims for Relief
A.Z. now brings suit under ERISA, on behalf of a putative class, contending that Defendants have improperly denied benefits under the Plan and breached their fiduciary duties to adjudicate benefits determinations in violation of applicable law, including the Paul Wellstone and Pete Domenici Mental Health Parity and Addition Equity Act, see 29 U.S.C. § 1185a (the "Parity Act"), and the Affordable Care Act (the "ACA"), 42 U.S.C. § 300gg-5(a) ; 29 U.S.C. § 1185d. See Amended Complaint at ¶¶ 2-4, 63-73, 98-103.
A.Z. asserts four claims. Her first claim alleges that Defendants' denial of the costs of attending the Evoke wilderness program was improper under ERISA and seeks to recover any benefits due, along with a declaration of rights to coverage. Id. at ¶¶ 84-88. Her second claim asserts that Defendants' improper denial of coverage was a breach of Defendants' fiduciary duties imposed by ERISA. Id. at ¶¶ 89-95. Her third claim seeks to enforce the Plan, alleges a violation of the Parity Act and the ACA, and seeks to recover the benefits due to A.Z. under the Plan. Id. at ¶¶ 96-103. Her fourth claim asks for equitable remedies under ERISA for Defendants' violation of the Parity Act and the ACA. Id. at 104-06.
Defendants put forth three primary arguments in support of their Motion seeking dismissal of the Amended Complaint under Federal Rule of Civil Procedure 12(b)(6). First, Defendants argue that A.Z. has failed to allege sufficient facts establishing that the Plan covered the Evoke wilderness program in the first instance, thereby precluding recovery. Motion at 1, 7-11. Second, Defendants contend that the "Counseling in the Absence of Illness" exclusion expressly excludes coverage for the Evoke wilderness program. Id. at 1, 11-12. Third, Defendants argue that A.Z. has failed to adequately plead Parity Act and ACA violations. Id. at 13-21.
Discussion
I. Motion to Dismiss Standard
A complaint challenged by a Rule 12(b)(6) motion to dismiss must offer "more than labels and conclusions" and contain more than a "formulaic recitation of the elements of a cause of action." Bell Atl. Corp. v. Twombly ,
Plaintiff has attached various documents to the Amended Complaint, including the Plan and documents regarding A.Z.'s appeal of Defendants' decision to deny coverage. In deciding the Motion, the Court will consider all of these documents attached to the Amended Complaint without converting the Motion to one for summary judgment. See Parks Sch. of Bus., Inc. v. Symington ,
II. Coverage Under the Plan (First and Second Claims)
A.Z.'s first and second claims hinge on whether the Plan provided coverage for the Evoke wilderness program. If no coverage exists, then A.Z. cannot succeed on her claim to recover benefits or for breach of fiduciary duties for denying such benefits.
A. The Plan covers Mental Health Services for treatment of Mental Health Conditions
The Plan covers "Mental Health Services for treatment of Mental Health Conditions." Plan at Regence 0041. Clarifying this term, the Plan provides the following definitions:
Mental Health Conditions means mental disorders in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association except as otherwise excluded in this [Plan].
Mental Health Services means Medically Necessary outpatient services, Residential Care, partial hospital program or inpatient services provided by a licensed facility or licensed individuals with the exception of Skilled Nursing Facility Services ....
Residential Care means care received in an organized program which is provided by a residential facility or Hospital, or other facility licensed, for the particular level of care for which reimbursement is being sought, by the state in which the treatment is provided.
*10751. Mental Health Condition
The Amended Complaint alleges that "A.Z. has a diagnosed mental illness, depression, which is contained in the most recent edition of the DSM [Diagnostic and Statistical Manual of Mental Disorders]." Amended Complaint at ¶ 24. Thus, A.Z. has alleged that she suffers from a Mental Health Condition expressly covered by the Plan. Plan at Regence 0041. A.Z. alleges that, to treat this condition, her doctors recommended that she attend Evoke's wilderness program. Amended Complaint at ¶ 19.
2. Mental Health Services & Residential Care
Addressing the Plan's "Residential Care" definition, the parties' dispute whether the Evoke wilderness program was (1) an organized program (2) provided by a facility that was (3) licensed for the particular level of care for which reimbursement was sought. As to the first issue, the Amended Complaint alleges that "Evoke is, and was while A.Z. received treatment, licensed as an 'outdoor youth program.' " Amended Complaint at ¶ 20, Exhibit B. Evoke's licensing certificate expressly authorizes Evoke to operate an "Outdoor Youth Program" pursuant to ORS 418.205 through .327. Id. , Exhibit B. ORS 418.205(6)(a) defines "outdoor youth program" as "a program that provides, in an outdoor living setting, services to children who have ... mental health problems ...." See also Amended Complaint at ¶ 21 (quoting the statute). The Amended Complaint's allegations that Evoke's wilderness program is "an organized program" licensed by the State of Oregon fall squarely within the definition of Residential Care provided by the Plan. Plan at Regence 0041.
Concerning whether Evoke is a "facility" within the definition of Residential Care, the Amended Complaint alleges that Evoke is both a "residential facility" and "facility" under the Plan's definition of Residential Care. Amended Complaint at ¶ 2. The Plan does not define the word "facility," and Defendants urge the Court to apply the term's ordinary meaning in arguing that a "facility" should be limited to a "brick and mortar" structure. See Motion at 9.
Defendants' "brick and mortar" argument is unconvincing, as the ordinary meaning of "facility" is not so restrictive. The common dictionary definition of "facility" supplied by Defendants includes "something ... that is ... established to serve a particular purpose." Facility, Merriam-Webster's Dictionary (11th ed. 2018), available at https://www.merriam-webster.com/dictionary/facility. That same dictionary also provides an alternative definition of facility, which Defendants appear to ignore: "something that makes an action, operation, or course of conduct easier[.]" Id. Drawing all inferences in favor of A.Z., as it must on a motion to dismiss, the Court concludes that Evoke's wilderness program could plausibly qualify as a "facility" under both definitions. On the one hand, A.Z. alleges that Evoke was established to serve the particular purpose of providing treatment to children suffering from various conditions, including depression. See, e.g. , Amended Complaint at ¶¶ 1, *10763, 19-21.
Finally, the Court is satisfied that it is at least plausible that Evoke was "licensed for the particular level of care for which the reimbursement is being sought." Plan at Regence 0041. The Claim Forms attached to the Amended Complaint as Exhibit 11 show that Evoke sought reimbursement for "PSYCH-OUTDOOR B/H PROGRAM" using billing code "1001." See Amended Complaint, Exhibit F (Evoke Claim Forms). This description aligns with the level of care that Evoke is authorized to provide under its license issued by the State of Oregon. See ORS 418.205(6)(a).
Ignoring the description Evoke used in seeking reimbursement, Defendants argue that Evoke improperly sought reimbursement using the "1001" code, which should be reserved for "residential treatment." Motion at 11; Reply at 5-6. Defendants conclude that because Evoke was not licensed to provide residential treatment, it sought reimbursement for a level of care that it was not licensed to provide. Id. Even if Defendants are correct-an issue that is best left for the discovery phase of this litigation-the competing inference, if any, created by Evoke's use of the "1001" code must be resolved against Defendants and in A.Z.'s favor. Defendants' argument is therefore insufficient to warrant dismissal of A.Z.'s first and second claims.
Together, the Amended Complaint plausibly alleges that the Evoke wilderness program was an "organized program" and a "facility" licensed for the particular level of care for which reimbursement was sought. Thus, the care that Evoke provided to A.Z. was "Residential Care" falling within the Plan's definition of "Mental Health Services." Because A.Z.'s depression is a "Mental Health Condition" under the Plan, the Court is satisfied that the treatment she received at the Evoke wilderness program is plausibly covered by the Plan.
B. Whether Evoke's wilderness program is excluded
The Amended Complaint also alleges that Defendants improperly denied coverage by relying on the Plan's "Counseling in the Absence of Illness" exclusion. Amended Complaint at ¶¶ 1-4, 44-53, 56, 59-62. Defendants argue that A.Z. "fails to assert plausible assertions that the 'Counseling in the Absence of Illness' exclusion does not apply under the plain language of the Plan." Motion at 11-12. The Plan's Counseling in the Absence of Illness exclusion provides that:
Services for counseling in the absence of illness, not expressly described in this plan as a Covered Service, will not be covered. Examples of non-covered services: educational, social, image, behavioral or recreational therapy; sensory movement groups; marathon group therapy; sensitivity training; Employee Assistance Program (EAP) services; [and] wilderness programs ....
*1077
On its face, this exclusion only applies in the absence of illness not described in the Plan as Covered Service. The Amended Complaint alleges that A.Z. was diagnosed with an illness (depression) and attended the wilderness program to treat that illness. It makes no difference that the exclusion lists "wilderness programs" as an example of a non-covered service, as that example is only illustrative of situations where wilderness program services are rendered "in the absence of illness."
C. Whether A.Z. has adequately pleaded Plan losses in support of her second claim for breach of fiduciary duties
Defendants also argue that the Court should dismiss Plaintiff's second claim for breach of fiduciary duties under
III. Parity Act Violation (Third and Fourth Claims)
Finding that the Amended Complaint plausibly alleges coverage under the Plan, the Court turns to A.Z.'s third and fourth claims. The gravamen of those claims is whether Defendants' alleged exclusion of benefits violated the Parity Act. Under the *1078Parity Act, a group health plan must ensure that (1) the "treatment limitations" applicable to mental-health benefits are "no more restrictive than the predominate treatment limitations applied to substantially all medical and surgical benefits covered by the plan" and (2) "there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits." 29 U.S.C. § 1185a(a)(3)(A)(ii). The implementing regulations provide that a plan:
may not impose a nonquantitative treatment limitation with respect to mental health ... benefits in any classification unless, ... any processes, strategies, evidentiary standards, or other factors used in applying the nonquantitative treatment limitation to mental health ... benefits in the classification are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation with respect to medical surgical/benefits in the classification.
The pertinent inquiry is whether Defendants' refusal to cover "wilderness programs" is an exclusion that applies equally to medical/surgical benefits and mental health or substance use disorder benefits. The Amended Complaint alleges that Regence "excludes coverage of outdoor/wilderness behavioral healthcare programs for mental illnesses, even though it covers medical treatment provided in other types of intermediate residential programs, such as skilled nursing care." Amended Complaint at ¶ 2. "While Regence generally covers medical and surgical services when provided in intermediate settings, it has a practice of excluding wilderness therapy - a form of intermediate therapy to treat mental illnesses. This practice is alleged to occur even when exclusion is not permitted by the Plan's terms."
Defendants argue that A.Z. has (1) misidentified the relevant exclusion by focusing on a "blanket exclusion" not found in the Plan; and (2) failed to allege the relevant "processes, strategies, evidentiary standards, or other factors" Regence employed in deciding to exclude wilderness programs. Motion at 14-19. In making these arguments, Defendants rely heavily on Welp v. Cigna Health & Life Ins. Co. , No. 17-cv-80237,
A. Welp does not resolve whether the Amended Complaint sufficiently alleges a Parity Act violation
In Welp , the court granted the plan administrator defendants' motion to dismiss *1079a complaint for failure to allege a Parity Act violation.
The Welp plaintiff alleged that "the Plan's terms impermissibly create[d] a separate and non-quantitative limitation on specific mental health benefits" in violation of the Parity Act. Id. at *4. The Welp court rejected the plaintiff's argument that the defendants maintained a "blanket exclusion for services at wilderness treatment centers." Construing the plan documents, the court concluded that the defendants properly applied the plan's criteria for determining whether a program is covered. Specifically, the court noted that the reasons defendants gave in denying coverage-including the program's lack of a multidisciplinary team and consistent supervision of professionals-were legitimate criteria listed in the plan and qualified as non-quantitative treatment limitations under the Parity Act. Id. at *5. In drawing this conclusion, the court reasoned as follows:
the denial of coverage for a requested benefit pursuant to a limitation is not the same thing as an ex ante limitation prohibiting coverage for that benefit. To properly plead a Parity Act violation resulting from the denial of the wilderness program's coverage, the first thing Plaintiff must do is correctly identify the relevant limitation-here, the distinction between qualifying and non-qualifying PRTFs.... Alternatively, Plaintiff might simply allege that [the wilderness program] did meet the PRTF criteria.
Here, A.Z. alleges both theories identified by the court in Welp . Although she alleges that the face of the Plan impermissibly excludes wilderness programs in violation of the Parity Act, she also alleges that the wilderness program satisfied all criteria for coverage under the Plan. In contrast to the pertinent plan provisions at issue in Welp that excluded all wilderness programs that did not qualify as PRTFs, the Plan here merely lists wilderness programs as an example of an excluded service that would not be covered "in the absence of illness." Without specifying any criteria that could be analogized to the pertinent non-quantitative treatment limitations articulated in the Parity Act, Defendants explained that, under their interpretation of the Plan, wilderness programs are not covered. For example, in their October 17, 2016 denial letter, Defendants stated that "this is not a determination of medical necessity; rather, it is a limitation of your health care contract." Amended Complaint, Exhibit D.
*1080Because the Amended Complaint alleges that the Plan covers the services A.Z. received at the Evoke wilderness program, Welp does not control the outcome of this case. To the contrary, the Welp court tailored its decision to the specific terms of the plan at issue and left open the possibility of alternative avenues for pleading a Parity Act violation. On its face, the decision carefully avoids answering whether a complaint alleging that a wilderness program met the criteria for coverage under a plan is sufficient to state a Parity Act claim.
B. The post- Welp case law expands on the pleading criteria identified in Welp
A handful of decisions after Welp further guide the Court's analysis of this issue. In Danny P. v. Catholic Health Initiatives ,
However, unsurprisingly, it does not specifically address the precise scope of the Parity Act provisions for the myriad ... situations that might arise. That leaves room for interpretation. Put otherwise, it has necessarily left some room for uncertainty or ambiguity regarding its application to specific ERISA plan terms and situations.
Two newer decisions specifically considered whether the denial of "wilderness program" coverage violated the Parity Act. In A.H. , the plaintiff argued that defendants' blanket exclusion for wilderness programs violated the Parity Act because it imposed stricter limitations on mental health and substance abuse treatment than it did for medical and surgical care. A.H. ,
More recently, the United States District Court for the District of Massachusetts reached a different conclusion. In Vorpahl v. Harvard Pilgrim Health Ins. Co. , No. 17-cv-10844-DJC,
The Vorpahl court found these allegations sufficient to state a Parity Act claim: "Although it may be a 'close call,' it appears sufficient to allege, as Plaintiffs have, 'that a mental-health treatment is categorically excluded while a corresponding medical treatment is not' to state a Parity Act claim." Id. (quoting Bushell v. Unitedhealth Grp. Inc. , 17-cv-2021-JPO,
Although the courts seemed to have reached different outcomes, the holdings in A.H. and Vorpahl are not at odds-and align with the framework identified in Welp . These cases demonstrate that a plaintiff alleging a facial Parity Act violation must properly identify, either in the terms of the plan or the administrative record, the relevant treatment limitation supporting that charge. A.H. ,
C. A.Z. sufficiently pleads both "categorical" and "as applied" Parity Act violations
A.Z. mounts a facial attack by relying on the terms of the Plan; disputes Defendants' categorical denial of wilderness program benefits; and challenges Defendants' practice of excluding wilderness programs-independent of the terms of the Plan. She succeeds on her second and third theories. On its face, the Plan does not violate the Parity Act because its terms are neutral. A.H. ,
Likewise, A.Z. alleges that "[w]hile Regence generally covers medical and surgical services when provided in intermediate settings, it has a practice of excluding wilderness therapy - a form of intermediate therapy to treat mental illnesses. This practice occurs even when exclusion is not permitted by the plan ." Amended Complaint at ¶ 67 (emphasis added). Put differently, A.Z. contends that the improper exclusion occurs in application rather than by the Plan's terms. These allegations are also a sufficient, independent basis to allege a Parity Act claim, see Vorpahl ,
In sum, the Court concludes that A.Z. has met the applicable pleading standards in stating a Parity Act violation. This conclusion furthers the equitable concerns articulated by the Ninth Circuit in Danny P. and allows A.Z. to develop her legal theories on the merits. Danny P. ,
IV. ACA Violation (Third and Fourth Claims)
A.Z. further alleges that Regence's application of the "Counseling in the Absence of Illness" exclusion violates the provider non-discrimination provision of the ACA. Amended Complaint at ¶¶ 3, 70, 98, 102. A.Z. relies on 42 U.S.C. § 300gg-5(a), which provides that "a group health plan and a health insurance issuer offering group or individual health insurance *1083coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State law." Amended Complaint at ¶ 102. But Section 300gg-5 does not create a private right of action. Vorpahl ,
Conclusion
For the foregoing reasons, the Court ORDERS:
(1) Defendants' motion to dismiss A.Z.'s first claim is DENIED.
(2) Defendants' motion to dismiss A.Z.'s second claim is GRANTED. A.Z.'s second claim is DISMISSED with prejudice.
(3) Defendants' motion to dismiss A.Z.'s third and fourth claims is DENIED.
(4) The Clerk is directed to send a copy of this Order to all counsel of record.
IT IS SO ORDERED.
On February 15, 2018, the Court dismissed without prejudice the original complaint, docket no. 1, for failure to state a claim. See docket no. 33. A.Z. filed the operative amended complaint, docket no. 36 (the "Amended Complaint"), on March 16, 2018.
Plaintiff's Opposition to Defendants' Motion to Dismiss, docket no. 44, is referred to as the "Opposition." Defendants' Reply in Support of Motion to Dismiss, docket no. 46, is referred to as the "Reply."
The Plan is attached to the Amended Complaint at docket no. 36-1.
"Regence Blueshield is a Washington non-profit corporation and Cambria Health Solutions, Inc., an Oregon non-profit private corporation, is the ... sole member of Regence Blueshield." Corporate Disclosure Statement, docket no. 24.
As discussed below, A.Z. could arguably still succeed on a Parity Act or ACA theory even in the absence of coverage under the Plan.
A.Z. argues that Defendants waived any argument that treatment at Evoke is not covered under these terms of the Plan. Opposition at 1-2, 6-7, 24. In general, a plan administrator cannot raise new reasons for denying coverage if it did not raise them during the administrative process. Harlick v. Blue Shield of Cal. ,
The same conclusion can be drawn by applying the Oxford Dictionary definition, which explains that a "facility" is "[a] place, amenity, or piece of equipment provided for a particular purpose." Facility, Oxford English Dictionary (2nd ed. 1989). The Amended Complaint adequately establishes that Evoke provides its wilderness program as a place where children can be treated for mental disorders.
The Court therefore need not determine whether Evoke is a "residential facility."
To the extent the exclusion's reference to "wilderness programs" creates any ambiguity, such ambiguity must be resolved in A.Z.'s favor at this stage of the litigation. Blankenship v. Liberty Life Assur. Co. ,
Defendants suggest that "[i]t is within the grasp of a person of ordinary intelligence and experience to comprehend that the contract's exclusion of 'wilderness programs' would operate to exclude the Evoke wilderness program." Motion at 12. This argument ignores the question presented: whether Defendants improperly applied the exclusion in denying coverage to A.Z. The Court finds that the Amended Complaint has adequately alleged coverage and that Defendants improperly denied coverage.
Defendants also argue that A.Z. lacks standing to seek injunctive and declaratory relief under Section 1132(a)(1) because she cannot demonstrate a sufficient likelihood of future injury. Motion at 22-24. A.Z., on behalf of the putative class, seeks "a declaration of their rights to coverage of medically necessary mental health treatment in outdoor-wilderness behavioral programs without the application of Regence's blanket exclusions and limitations." Amended Complaint at ¶ 88. Consistent with this allegation, an ERISA beneficiary may bring a civil action to clarify her rights to future benefits under a plan and may do so without showing a threat of future harm. A.H. v. Microsoft Corp. Welfare Plan , No. C17-1889-JCC,
The Court dismissed A.Z.'s original version of this claim with leave to amend on the same basis. Plaintiff has failed to address this issue. See Complaint (Class Action), docket no. 1, at ¶¶ 28-35; docket no. 33.
The regulations provide six classifications: inpatient, in-network; inpatient, out-of-network; outpatient, in-network; outpatient, out-of-network; emergency care; and prescription drugs.
The Court also relied on Welp in dismissing A.Z.'s original complaint. See docket no. 33.
Unlike the exclusion at issue in this case, the exclusion in A.H. expressly excluded coverage for "educational or recreational therapy programs; this includes, but is not limited to boarding schools and wilderness programs ...."
The court in Bushell also referred to this issue as a "close call," but concluded that the complaint adequately alleged a Parity Act violation at the motion to dismiss stage. Bushell ,
For this reason, the Court finds Defendants' "cross-walking" argument unpersuasive. See Motion at 17-18.
A.Z. argues "that her treatment was an otherwise covered service that was excluded because it was provided by [a] provider whose license permitted it to offer services in the wilderness." Opposition at 21-22. The Court rejects this argument, as the ACA's anti-discrimination provision does not require a plan to provide coverage for any treatment simply because it is rendered by a state-licensed provider. A.H. ,
Reference
- Full Case Name
- A.Z., BY AND THROUGH her parents and guardians, E.Z. and D.Z., individually, and on behalf of the Juno Therapeutics, Inc., Health Benefits Plan, and on behalf of similarly situated individuals and plans v. REGENCE BLUESHIELD and Cambria Health Solutions, Inc., f/k/a The Regence Group
- Cited By
- 28 cases
- Status
- Published