In Re

Complainant: Pensioner
Respondent: Employer
ROD Case No: 07-0057 – July 26, 2011

Trustees: Micheal W. Buckner, Daniel L. Fassio, Morris D. Feibusch, and Michael
H. Holland

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

Complainant’s spouse received treatment for chronic sinus problems and was referred to an ear, nose and throat specialist. The specialist made a diagnosis of rhinosinusitis and recommended surgical procedures known as a nasal septoplasty and a bilateral inferior turbinate hypertrophy to resolve the chronic condition. The specialist submitted a request to Respondent for pre-authorization of the recommended surgical procedures, but Respondent determined that the procedures were not medically necessary and denied their pre-authorization.


Are the requested surgical procedures medically necessary within the meaning of the 2007 Employer Benefit Plan?

Positions of the Parties

Position of the Complainant: The procedures were recommended by an ear, nose and throat specialist and are, therefore, medically necessary.

Position of the Respondent: The requested surgical procedures are not medically necessary; therefore, Respondent is not required to provide coverage for the procedures.

Pertinent Provisions

The introduction to Article III of the Employer Benefit Plan states in pertinent part:


…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; 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.

* * *

The introduction to Article III of the Employer Benefit Plan states that coverage will only be provided for services that are medically necessary. The Funds’ Medical Director has reviewed the facts of this case, including medical records and a report of a CT scan of the Complainant’s
spouse’s paranasal sinuses, and opines that the proposed surgical procedures do not satisfy the medical necessity requirements of Article III of the Employer Benefit Plan.

Opinion of the Trustees

Consistent with the provisions of the Employer Benefit Plan, the requested surgical procedures are not medically necessary, and, therefore, Respondent is not required to cover them.