K.

I. FACTUAL BACKGROUND

1 A. Plan Terms 2 Effective October 1, 2014, plaintiff E.K., through her father, plaintiff Josef K., was 3 covered under a group health plan issued by Blue Shield (“the Plan”). Under the terms of the 4 Plan, treatment is covered only if it is “Medically Necessary,” defined in relevant part as follows: 5 1. Services which are medically necessary include only those which have been established as safe and effective, are furnished under generally accepted professional standards to treat illness, injury or medical condition, and which, as 7 determined by Blue Shield, are: a. consistent with Blue Shield of California medical policy; b. consistent with the symptoms or diagnosis; c. not furnished primarily for the convenience of the patient, the attending 10 Physician or other provider; and d. furnished at the most appropriate level which can be provided safely and effectively to the patient. 12 2. If there are two or more medically necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide benefits based on the most cost-effective service. 14…