OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
In Re
Employee
Employer
11-0115 – November 6, 2015
Michael H. Holland, Marty D. Hudson, Michael O. McKown and Joseph R. Reschini
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 is an employee of the Respondent. The Complainant sought medical treatment in the emergency room on Wednesday, January 30, 2013, at 11 a.m., for complaints of facial pain and swelling that he had experienced for seven days following a tooth extraction. He reported nothing relieved his symptoms. He was diagnosed with a dry socket and sent home with four Percocet tablets and an antibiotic. After discharge, the CT scan results showed a questionable abscess lateral to the mandible. The patient was notified and advised to see a dentist.
The Respondent denied the emergency room facility charge and the ancillary charges of the emergency room physician and the CT scan, stating that the patient’s coverage did not provide for this service when performed for the diagnosis reported. When requested, the Respondent would not conduct a review of the denial decision because the appeal was submitted after the 180-day deadline for receipt of an appeal.
Dispute
Is the Respondent required to provide benefits for the Complainant’s emergency room visit on January 30, 2013, that include emergency room facility expenses and the ancillary charges for the physician and CT scan related to the emergency room visit?
Positions of the Parties
Position of the Complainant: All of the charges are a covered benefit under the Employer Benefit Plan.
Opinion of Trustees ROD Case No. 11-0115 Page 2
Position of the Respondent: The Respondent did not submit a response to the complaint.
Pertinent Provisions
The introduction to Article III of the Employer Benefit Plan states:
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 the Plan.
Article III A (2)(a) of the Employer Benefit Plan states:
III BENEFITS
A. Health Benefits
(2) Outpatient Hospital Benefits
(a) Emergency Medical and Accident Cases
Benefits are provided for a Beneficiary who receives emergency medical treatment or medical treatment of an injury as the result of an accident, provided such emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of the accident.
Article III A (3)(e) of the Employer Benefit Plan states:
III. BENEFITS
A. Health Benefits
(3) Physicians’ Services and Other Primary Care (e) Oral Surgery
Benefits are not provided for dental services. However, Benefits are provided for the following limited oral surgical procedures if performed by a dental surgeon or general surgeon: tumors of the jaw (maxilla and mandible) wiring, freneculectomy when related only to ankyloglossia (tongue tie), biopsy of the oral cavity, fractures of the jaw, including reduction fractures of the facial bones, temporomandibular joint dysfunction, only when medically necessary and related to an oral orthopedic problem, dental services required as the direct result of an accident.
The Introduction to Article III of the Employer Benefit Plan states:
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.
Opinion of Trustees ROD Case No. 11-0115 Page 3
Discussion
Article III.A(2)(a) of the Employer Benefit Plan provides benefits for emergency medical treatment if the emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms. The patient here had been experiencing symptoms of pain and swelling for seven days prior to seeking treatment at the emergency room and therefore, did not meet the 48-hour requirement. The Funds’ Medical Director reviewed the clinical records from the emergency room visit and did not find any reference to any extenuating clinical circumstances, such as recent increase in pain or swelling. Therefore, the acuity of the patient’s symptoms should have been able to have been managed by the dentist who did the tooth extraction if the dentist had been notified of the ongoing symptoms, and the patient should have sought treatment with his dentist.
Article III A.(3)(e) of the Employer Benefit Plan states that benefits are not provided for dental services. The patient’s symptoms were entirely dental related and did not meet any of the limited oral surgical procedures on the list.
Further, the Introduction to Article III of the Employer Benefit Plan states that, “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.” There was no information in the emergency room records that indicated the patient had contacted his dentist after the tooth extraction regarding his symptoms. It is the opinion of the Funds’ Medical Director that the patient should have contacted the dentist who performed the tooth extraction prior to seeking treatment at the emergency room. Thus, even though a physician ordered the CT scan, it does not mean that the CT scan is covered under the Plan.
Based on the foregoing, the charges for Complainant’s emergency room visit on January 30, 2013, that include emergency room facility expenses, the ancillary charges for the physician related to the emergency room visit, and the charges for the CT scan do not satisfy the criteria necessary to be covered under the Plan. The Complainant did not meet the 48-hour requirement for emergency services, the type of treatment he received was not covered under the Plan’s limited oral surgery provisions delineated in the Plan, and although a physician ordered the CT scan it does not mean that it was reasonable or necessary as required by the Plan. Thus, the Employer should not be responsible for the emergency room facility expenses or any ancillary charges, including the professional fee charges or CT scan charges related to the emergency room visit.
Opinion of Trustees ROD Case No. 11-0115 Page 4
Opinion of the Trustees
Pursuant to Article III A. (2)(a), Article III A.(3)(e), and the Introduction to Article III of the Employer Benefit Plan, the Respondent is not required to provide benefits for Complainant’s emergency room visit on January 30, 2013, and is not required to pay for the emergency room physician charges or the CT scan associated with this visit.