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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 02-018 – June 22, 2005
Trustees: Micheal W. Buckner, A. Frank Dunham, Michael H. Holland, and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
Background Facts
The Complainant, who is employed by the Respondent, paid for chelation therapy treatments administered by a physician from May 10, 2004, through October 5, 2004. According to the American Heart Association, Chelation therapy is administering a man-made amino acid called ethlylenediamine tetraacetic (EDTA) into the veins. EDTA is most often used in cases of heavy metal poisoning (lead or mercury) because it binds with these metals creating a compound that can be excreted in the urine.
The Complainant’s physician stated that the Complainant was being treated for heavy metal toxicity: a hair analysis revealed high levels of Aluminum, Antimony and Arsenic and a urinalysis revealed higher than normal levels of Mercury, Antimony Tin and Copper. The Complainant’s symptoms included muscle weakness, fatigue, headaches, and loss of smell and taste.
According to the Complainant, the chelation treatments were done to remove heavy metals. Prior to the chelation treatments, the Complainant stated that he was unable to work, and he returned to full time employment after the treatments.
Dispute
Is the Respondent required to reimburse the Complainant for the chelation therapy that the Complainant received from May 10, 2004 through October 5, 2004?
Positions of the Parties
Position of the Complainant: The Respondent is required to provide reimbursement for the chelation therapy because the treatments were successful and the Complainant was able to return to full time employment.
Position of the Respondent: The Respondent is not required to reimburse the Complainant for the chelation therapy because the treatment does not meet the medical necessity criteria under the Employer Benefit Plan. Moreover, based on customary practices of physicians in the community where the service is provided, chelation therapy was not the appropriate treatment in this case. The Respondent referred to RODs 84-712, 88-128 and 88-729 to support its position.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states:
ARTICLE III BENEFITS
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan. In determining questions of reasonableness and necessity, due consideration will be given to the customary practices of physicians in the community where the service is provided. Services which are not reasonable and necessary shall be included, but are not limited to the following: procedures which are of unproven value or of questionable current usefulness; procedures which tend to be redundant when performed in combination with other procedures; diagnostic procedures which are unlikely to provide a physician with additional information when they are used repeatedly; procedures which are not ordered by a physician or which are not documented in timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care. Covered services that are medically necessary will continue to be provided, and accordingly this paragraph shall not be construed to detract from plan coverage or eligibility as described in this Article III.
Discussion
The Introduction to Article III of the Employer Benefit Plan states that covered services are limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury.
In this case, the patient received chelation treatments from May 10, 2004, through October 5, 2004. The Funds’ Medical Director reviewed the information submitted in this file including the laboratory results of the hair and urine samples. According to the Medical Director, neither the hair analysis nor the urine clearance tests are considered by the medical community to be the standard of practice in diagnosing metal toxicity and are generally considered to be non-covered laboratory tests. Standard medical practice is to confirm the diagnosis of patients exhibiting the symptoms of metal toxicity with serum blood tests that show the specific blood levels of the various metals of concern. There is no evidence in this case that these blood tests were done prior to administering the chelation treatments. In addition, chelation therapy using EDTA in patients diagnosed with elevated serum levels is done over a short period of time of five to seven days and is indicated primarily only for acute lead intoxication. It is not effective in reducing copper or mercury, two of the several elevated metals that the Complainant’s physician claimed to be treating in this case.
According to the American Heart Association, kidney failure, bone marrow depression, and low blood pressure are some of the medical concerns associated with chelation therapy.
The Medical Director is of the opinion that the treatment in this case was not a reasonable and necessary medical treatment of an illness or injury and would not be covered under Article III of the Employer Benefit Plan.
Coverage for chelation therapy has previously been addressed by the Trustees in RODs 88-128, 84-712 and 88-729. In RODs 84-712 and 88-128, the Trustees determined that there was no evidence of a medical condition that required chelation therapy. More analogous to the present case, the pensioner in ROD 88-729 received chelation therapy based on laboratory results of hair and urine samples that indicated extremely high levels of lead and iron. The Trustees concluded that the use of chelation therapy was not medically necessary and the Employer was not required to provide coverage.
Opinion of the Trustees
The Respondent is not required to reimburse the Complainant for the chelation therapy that the Complainant received from May 10, 2004, through October 5, 2004.