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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 81-674 – January 28, 1986
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.
Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits for biofeedback therapy under the terms of the Employer Benefit Plan.
Background Facts
The Employee has been treated for anxiety neurosis on an inpatient as well as an outpatient basis. He was hospitalized from May 21, 1984 through May 25, 1984 for this condition. At the time of discharge, his attending physician “recommended and planned” that the Employee undergo biofeedback therapy “as an integral part of his treatment.” The Employer has denied payment for this service under the provisions of Q&A 81-42 (enclosed herein).
Dispute
Is the Employer responsible for payment of charges for biofeedback therapy as part of the treatment of the Employee’s anxiety neurosis?
Positions of the Parties
Position of the Complainant: The Complainant contends that this therapy should be considered a covered benefit for treatment of his anxiety neurosis.
Position of the Respondent: The Respondent contends that the charges for the Employee’s biofeedback therapy were properly denied in accordance with the provisions of Q&A 81-42.
Pertinent Provisions
Article III A (11) (a) 24 of the Employer Benefit Plan provides:
(a) In addition to the specific exclusions otherwise contained in this plan, benefits are also not provided for the following:
24. Charges for treatment with new technological medical devices and therapy which are experimental in nature.
Q&A – 81-42 (Revised September 3983).
References: Amended 1950 and 1974 Benefit Plans and Trusts Article III A (7) (f) and A (11) 24.
Question: Are benefits provided for biofeedback therapy?
Answer: Biofeedback therapy is generally a non-covered benefit. Biofeedback may be covered, however, when prescribed by a physician, and when it is reasonable and necessary for an individual patient for muscle re-education of specific muscle groups for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm or weakness and only when more conventional treatments (such as heat, cold, massage, exercise, support) have been attempted and have not been successful.
Payment for biofeedback therapy, when covered, will be made only to aphysician, clinic or hospital.
Discussion
Under Article III A (11) (a) 24 of the Employer Benefit Plan, charges for treatment with new technological medical devices and therapy which is experimental in nature are excluded from coverage. According to Q&A 81-42 biofeedback therapy is generally a non-covered benefit except when certain criteria have been satisfied. This Q&A is consistent with Medicare’s current coverage guidelines for this therapy.
A Funds’ consultant has reviewed the available information regarding the Employee’s biofeedback therapy and has determined that the criteria for coverage established in Q&A 81-42 have not been satisfied. The use of biofeedback therapy for the treatment of the Employee’s anxiety neurosis does not fall within the specific clinical categories for which biofeedback therapy may be considered a covered benefit under the provisions of Q&A 81-42. The Employer therefore is not responsible for payment of the charges relative to the Employee’s biofeedback therapy.
Opinion of the Trustees
The Employer is not responsible for providing benefits for the Employee’s biofeedback therapy used to treat his anxiety neurosis.