April 29, 1985

(Opinion issued in letter form; name and address deleted)

Re: Opinion of the Trustees
Resolution of Dispute
Case No. 81-551

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 coverage of your dependent’s reduction mammoplasty under the terms of the Employer Benefit Plan.

Article III A. (3) (f) of the Employer Benefit Plan establishes that reduction mammoplasty is not a covered surgical service without prior approval of the Plan Administrator. In your dispute, you stated that the Respondent has previously paid for this type of surgical procedure without prior approval; therefore, you contend your dependent was unaware of the requirement to obtain prior approval. The Respondent stated in its position with regard to the dispute that a review of its records indicated one case had been approved after the fact, based on individual facts which involved correction of a previous surgical procedure. Such an approval based on extenuating circumstances does not obligate the Plan Administrator to adopt a policy of waiving its prior approval requirement. The Respondent stated further that prior approval has been a highly publicized concept at its mines where multiple means, including publication of articles in newsletters, discussions led by personnel representatives, and training classes, have been used to make employees aware of situations which require prior approval.

In addition, when prior approval is sought, it can be granted only on the basis of fully documented medical necessity. The medical evidence provided to establish that your dependent’s reduction mammoplasty is a covered benefit fails to document the existence of physiological abnormalities indicating surgery was needed, or that more conservative therapies than surgery were prescribed unsuccessfully, to support your contention of medical necessity for this surgical procedure. Although you have obtained evaluations and opinions from several physicians subsequent to your dependent’s surgery, information regarding the pre-surgical condition has not been provided.

Because you neither sought nor obtained the prior approval of your Plan Administrator, your Employer is not responsible for coverage of the medical bills pertaining to your dependent’s reduction mammoplasty.
Joseph P. Connors, Sr., Chairman
Paul R. Dean, Trustee
William B. Jordan, Trustee
William Miller, Trustee
Donald E. Pierce, Jr., Trustee