OPINION OF TRUSTEES
ROD Case No: 07-0062 – December 15, 2011
Trustees: Micheal W. Buckner, Daniel L. Fassio, Morris D. Feibusch, and Michael
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
Complainant has a longstanding history of paroxysmal atrial fibrillation and underwent a pulmonary vein isolation procedure in 2008; however, Complainant has had recurrent atrial fibrillation since that time. Complainant received a cardiac CT scan on March 19, 2010, to evaluate his pulmonary venous anatomy in preparation for ablation therapy. Respondent’s insurance carrier informed Complainant’s physician that preauthorization was not required for the CT scan and that it would be covered. Respondent’s insurance carrier denied benefits for the CT scan, and upheld its denial twice on appeal, because it concluded that the CT scan was not medically effective for the condition being treated and was, therefore, considered experimental or investigative in nature.
Is Respondent required to provide benefits for the CT scan Complainant received on March 19, 2010, under the terms of the Employer Benefit Plan?
Positions of the Parties
Position of the Complainant: Respondent is required to provide benefits for the CT scan because it was medically necessary and performed in good faith reliance on the representation from Respondent’s insurance carrier that it would be covered.
Position of the Respondent: Respondent has not submitted a response to this ROD.
Article III of the 2007 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; 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 benefits described in this Article are subject to any precertification, prescription drug formulary (PDP) requirements, and other utilization review requirements implemented pursuant to Article IV. Covered services that are medically necessary will continue to be provided, and accordingly, while benefit payments are subject to prescribed limits, this paragraph shall not be construed to detract from plan coverage or eligibility as described in this Article III.
Article III. A(2)(c) states:
A. Health Benefits
(2) Outpatient Hospital Benefits
(c) Laboratory Tests and X-rays
Benefits are provided for laboratory tests and x-ray services performed in the outpatient department of a hospital which provides such services and when they have been ordered by a physician for diagnosis or treatment of a definite condition, illness or injury.
Article III of the Employer Benefit Plan provides benefits for laboratory tests and x-rays, including CT scans, which are medically necessary. The Funds’ Medical Director reviewed the medical records submitted in this ROD and determined that the CT scan Complainant received is a widely accepted procedure for his medical situation and was medically necessary.
Opinion of the Trustees
Respondent is required to provide benefits for the CT scan Complainant received on March 19, 2010.