March 1, 1984
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-410
Pursuant to Article IX of the United Mine Workers of America 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed your Request for Resolution of Dispute concerning the level of health benefit coverage for your cardiac rehabilitation services.
According to the information provided, you have participated in a hospital outpatient cardiac rehabilitation program, where you received group training and participated in exercises provided and supervised by a registered nurse and an exercise physiologist. Although you were referred to this program by your physician, your Employer has denied payment for these services.
Under 1981 Contract Question and Answer #81-14, attached hereto, benefits are provided for cardiac rehabilitation conducted in a hospital outpatient setting under the direct supervision of a physician. The services you received were provided by and under the supervision of a registered nurse and exercise physiologist, and not a physician. Although your physician was kept informed of your progress in this program, such involvement does not satisfy the requirement of physician’s supervision.
The Trustees therefore have determined that your Employer is not responsible for payment of the group training and exercise program which you participated in since these services were not conducted under a physician’s supervision.
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee
Control Number: 81-14
Subject: Cardiac Rehabilitation Programs in Outpatient Hospital Settings
Reference: Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Sections A (2) (c) and A (3) (j) and (o) 4
Are benefits provided if cardiac rehabilitation programs are conducted on an outpatient hospital basis?
Yes. Benefits are provided for such programs if conducted in an outpatient hospital setting. This includes coverage for stress testing, other medically necessary tests and associated therapy performed as part of the rehabilitation program. However, benefits are only provided for those parts of the program that are conducted under a physician’s direct supervision.