June 24, 1985
(Opinion issued in letter form; name and address deleted)
Re: ROD – Opinion of the Trustees
Resolution of Dispute
Case Number 81-591
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 allergy testing performed on your son between June 25, 1984, and August 30, 1984 under the terms of your Employer Benefit Plan.
According to the information provided, your son has been diagnosed as having allergic sinusitis and asthma. His attending physician has stated that these allergies were uncontrolled by conservative methods. In an effort to better diagnose and treat these allergies, his attending physician instituted sublingual testing and provocative dilution titration. Your Employer has denied coverage of the charges relative to this testing since in its opinion, this type of allergy testing has not been substantiated as medically necessary treatment and is experimental in nature.
Article III A (11)(a) 23 of your Employer Benefit Plan excludes from coverage charges for treatment with new technological medical devices and therapy which are experimental in nature. In light of your son’s diagnoses of allergic sinusitis and asthma, it is reasonable to conclude that allergy testing and desensitization are medically necessary components of the treatment of these conditions. Therefore, the issue in this dispute is whether sub-lingual testing and provocative dilution titration are experimental forms of allergy testing and desensitization.
These technologies have been adopted and utilized in some allergy practices for over two decades. Medicare does not categorize them as experimental forms of technological medical therapy. Based on the information available, the Trustees conclude that your Employer is responsible for coverage of the allergy services provided to your son.
Sincerely,
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Joseph P. Connors, Sr., Chairman
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Paul R. Dean, Trustee
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William B. Jordan, Trustee
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William Miller, Trustee
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Donald E. Pierce, Jr., Trustee