OPINION OF TRUSTEES
ROD Case No: 11-0080 – September 24, 2014
Trustees: Michael H. Holland, Michael McKown, Daniel R. Jack, and Marty D. Hudson
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
The complainant’s spouse sought prior approval for a power wheelchair and lift recommended by her attending physician to assist her in daily activities. The patient suffered a stroke with left hemiparesis, a lumbar spine fracture and surgical fusion, and has high blood pressure, diabetes and chronic back pain with inability to walk unaided.
Respondent’s Third Party Administrator approved the power wheelchair and denied the lift as ineligible for coverage under the terms of the Employer Benefit Plan.
Is Respondent required to provide benefits for Complainant’s spouse’s power lift?
Positions of the Parties
Position of the Complainant: The lift was prescribed by the attending physician and is a medically necessary, covered benefit under the Plan.
Position of the Respondent: Lifts are not covered under the terms of the Employer Benefit Plan and are not durable medical equipment as defined by the Plan.
Article III.A.(6)(d) of the Employer Benefit Plan states:
(6) Home Health Services & Equipment
(d) Medical Equipment
Benefits are provided for rental or, where appropriate, purchase of medical equipment suitable for home use when determined to be medically necessary by a physician.
Q&A 81-38 states, in pertinent part:
Question: What medical equipment and supplies are covered under the Plan?
A. Under the Home Health Services and Equipment provision, benefits are
provided for the rental and, where appropriate as determined by the Plan Administrator, purchase of medical equipment and supplies (including items essential to the effective use of the equipment) suitable for home use when determined to be medically necessary by a physician. These supplies and equipment include, but are not limited to the following:
1. Durable Medical Equipment (DME) which (a) can withstand use (i.e., could normally be rented), (b) is primarily and customarily used to service a medical purpose, (c) generally is not useful to a person in the absence of an illness or injury, and (d) is appropriate for use in the home. Examples of covered DME items are canes, commodes and other safety bathroom equipment, home dialysis equipment, hospital beds and mattresses, iron lungs, orthopedic frames and traction devices, oxygen tents, patient lifts, respirators, vaporizers, walkers and wheel chairs.
Article III.A.(6)(d) of the Employer Benefit Plan provides benefits for medical equipment when determined to be medically necessary by a physician. Medical equipment is defined in Q&A 81-38 as equipment and supplies suitable for home use and customarily used to service a medical purpose.
The Trustees have previously addressed the question of coverage for a lift for wheelchair-bound beneficiaries in RODs 81-131, 88-261, and 98-049 (copies enclosed). The opinion of the Trustees in those cases was that a wheelchair lift is not appropriate for use in the home and is not primarily and customarily used to serve a medical purpose. As in the cited RODs, the lift in this case would be used for transportation purposes outside the home and would not be used to serve a medical purpose. Therefore, the lift is not a covered benefit under Article III.A.(6)(d) of the Employer Benefit Plan.
Opinion of the Trustees
Pursuant to Article III.A(6)(d) of the Employer Benefit Plan, Respondent is not required to provide benefits for Complainant’s spouse’s power lift.