____________________________________________________________________________
OPINION OF TRUSTEES
____________________________________________________________________________
In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 07-0048 – January 12, 2011
Trustees: Michael H. Holland, Micheal W. Buckner, Daniel L. Fassio, and Morris D. Feibusch.
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 has been diagnosed with numerous medical conditions, including severe peripheral vascular disease and borderline osteoporosis. The attending physician started the Complainant on Vitamin D and requested testing for Vitamin D deficiency because a deficiency in this vitamin contributes to vascular disease progression. The Complainant was found to have a Vitamin D deficiency in an assay performed on February 18, 2009, and his intake of this vitamin was increased.
Four months later, on June 24, 2009, the Complainant was retested for Vitamin D and the level was normal. A follow-up test was performed on November 3, 2009, and this test also indicated a normal level of Vitamin D. The Respondent provided coverage for the first and second Vitamin D assays, but denied the charges for the third test performed on November 3, 2009.
Dispute
Is the Vitamin D assay performed on November 3, 2009, a covered benefit?
Positions of the Parties
Position of the Complainant: The Vitamin D assay performed on November 3, 2009, was prescribed by a physician and should, therefore, be a covered charge.
Position of the Respondent: The Respondent has not submitted a response to this ROD.
Pertinent Provisions
Article III of the Employer Benefit Plan states in pertinent part:
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 include, 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 . . . .
* * *
Article III.A(3)(j) of the Employer Benefit Plan states in pertinent part:
(3) Physicians’ Services and Other Primary Care
(j) Laboratory Tests and X-rays
Benefits will be provided for laboratory tests and x-rays performed in a licensed laboratory when ordered by a physician for diagnosis or treatment of a definite condition, illness or injury.
Discussion
Article III.A.(3)(j) of the Employer Benefit Plan provides benefits for laboratory tests that are ordered by a physician for the diagnosis or treatment of an illness or injury. A Vitamin D assay is a recognized laboratory procedure that is approved by Medicare if any one of a list of diagnostic criteria is met. The Funds’ Medical Director reviewed the documentation submitted in this dispute and is of the opinion that the Complainant met at least four of the diagnostic criteria on Medicare’s list. The Funds’ Medical Director concluded that the Vitamin D assay performed on November 3, 2009, was medically necessary and, therefore, a covered benefit.
Therefore, consistent with Article III.A.(3)(j) of the Employer Benefit Plan, the Respondent is required to provide benefits for this test.
Opinion of the Trustees
The Respondent is required to provide coverage for the Vitamin D assay ordered by a physician and performed on November 3, 2009.