August 27, 1985
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 84-053
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 coverage of transtelephonic electronic pacemaker analysis under the terms of your Employer Benefit Plan.
According to the information provided, your cardiac pacemaker requires certain diagnostic procedures in order to be maintained properly. Specifically, you have used transtelephonic monitoring of your pacemaker to insure its proper functioning. Your Employer has denied coverage of the charges relative to this service.
Article Ill A. (3) (o) 2. of your Employer Benefit Plan provides coverage for “…diagnostic procedures when medically necessary.” Recognizing that you require the use of an implanted cardiac pacemaker to maintain an acceptable level of cardiac function, it is reasonable to conclude that the proper maintenance and functioning of this unit is medically necessary in order to insure that the desired therapeutic result is achieved. Both the Funds and Medicare recognize that telephone monitoring of cardiac pacemakers is effective in identifying early signs of possible pacemaker failure and provide coverage of this service as a diagnostic procedure, subject to frequency guidelines published in the Medicare Carriers Manual. Based on the information available, the Trustees therefore conclude that your Employer is responsible for coverage of the transtelephonic-pacemaker monitoring you require.
Joseph P. Connors, Sr., Chairman
Paul R. Dean, Trustee
William B. Jordan, Trustee
William Miller, Trustee
Donald E. Pierce, Jr., Trustee