## Facts

- James and Gloria Linn bought an individual health insurance contract from BCBSM, Inc. (Blue Cross), which promised to timely pay for services that were both covered and “medically necessary” as defined by the contract and incorporated medical policies.
- The contract incorporated a medical policy governing proton-beam radiation therapy (PBRT) and told insureds they could pursue internal appeal and optional external review under Minn. Stat. § 62Q.73 after a medical-necessity denial.
- James Linn was diagnosed with a thoracic spine tumor, and his physician recommended PBRT.
- Blue Cross denied coverage, applying its PBRT policy and concluding PBRT for the tumor’s type and thoracic location was not “medically necessary” under the contract (characterized as investigative for non-specified locations).
- Linn requested an independent external review under Minn. Stat. § 62Q.73; while review was pending, he underwent significant surgeries.
- The external reviewer determined PBRT was medically necessary for Linn’s condition, and Blue Cross paid for PBRT after that decision.
- The Linns sued for breach of contract, alleging that an earlier approval of PBRT would have avoided later surgeries.

## Issues

1. What effect does an external-review determination under Minn. Stat. § 62Q.73, subd. 7(c) have on the parties’ contractual definition of “medically necessary” and on contractual liability?
2. Under the unambiguous contract and incorporated PBRT policy, was PBRT for Linn’s thoracic spine tumor covered as “medically necessary” for purposes of a breach-of-contract claim?

## Decision

- The Minnesota Supreme Court reversed the court of appeals and reinstated summary judgment for Blue Cross.
- An external-review decision is an independent statutory determination that creates only a statutory obligation to pay the claim; it does not alter or supersede the contract’s medical-necessity definition.
- Under the contract’s plain language and undisputed facts about tumor type and location, PBRT was excluded from coverage as not medically necessary under the contract.
- Blue Cross did not breach the contract by initially denying PBRT; its later payment reflected compliance with a statutory duty after external review, not contractual coverage.

## Legal Principles

- An external-review determination under Minn. Stat. § 62Q.73, subd. 7(c) imposes a statutory payment obligation and does not amend or rewrite the parties’ private contract.
- A health plan’s contractual duty to pay is limited to services that are both covered and “medically necessary” as defined in the contract and incorporated policies.
- Unambiguous insurance contract terms are enforced as written, and courts will not create coverage that the contract clearly excludes.
- Summary judgment is proper where contract language is unambiguous and there is no genuine dispute of material fact regarding facts that trigger an exclusion (here, tumor type and location under the PBRT policy).

## Conclusion

The court held that external review may require an insurer to pay a claim as a matter of statute, but it does not change contractual coverage terms; because the PBRT policy plainly excluded PBRT for the tumor’s undisputed type and thoracic location, the insureds could not recover contract damages for the initial denial.


Linn v. BCBSM, Inc., 905 N.W.2d 497 (Minn. 2018)