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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-242 – January 27, 1987
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 bilateral surgery, upper eyelid blepharoplasties, under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse was diagnosed by a plastic surgeon on April 26, 1985 as having slight blepharochalasis, excess upper-eyelid skin, which obstructed peripheral vision. A second plastic surgeon diagnosed the Employee’s spouse as having severe ptosis (drooping) of the eyelids with obstruction of vision, and then performed bilateral corrective surgery, known as blepharoplasty, on June 26, 1985. The Employee’s spouse has stated that she never sought nor obtained prior approval for the procedures. A preauthorization request form was submitted to an incorrect carrier by the first surgeon the Complainant consulted; the Complainant chose the second surgeon consulted to perform the surgery. The Employer has denied coverage for the procedures.
Dispute
Is the Employer responsible for the provision of health benefits coverage for the Employee’s spouse’s eye surgery, bilateral blepharoplasty?
Position of the Parties
Position of the Employee: The Employer is responsible for the provision of health benefits coverage for the Employee’s spouse because the purpose of the surgery was to correct a vision impairment.
Position of the Employer: The Employer is not responsible for the Employee’s spouse’s eye surgery because it was cosmetic surgery and is not therefore covered, in accordance with Article III. A. (3) (p) 9.
Pertinent Provisions
Article III. A. (3)(a) of the 1984 Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care
(a) Surgical Benefits
Benefits are provided for surgical services essential to a Beneficiary’s care consisting of operative and cutting procedure (including the usual and necessary post-operative care) for the treatment of illnesses, injuries, fractures or dislocations, which are performed either in or out of a hospital by a physician.
When surgical services consist of necessary major surgery (primary) and the physician performs surgery additional to the primary surgery (incidental surgery), benefits payment for the incidental surgery will be provided but at a rate of 50% lower than the physician’s normal charge had he performed only the incidental surgery.
Article III. A. (3)(p) of the 1984 Employer Benefit Plan states in part:
(p) Services Not Covered
9. Cosmetic surgery, unless pertaining to surgical scars or to correct results of an accidental injury or birth defects.
Discussion
Under Article III. A. (3)(a) of the Employer Benefit Plan, surgical benefits are provided for surgical services essential to a Beneficiary’s care consisting of operative and cutting procedure for the treatment of illnesses, injuries, fractures or dislocations, which are performed either in or out of a hospital by a physician. Article III A. (3)(p) 9 states that cosmetic surgery is not covered unless it is for correction of surgical scars, results of an accidental injury, or birth defects.
A Funds’ medical consultant has reviewed the available evidence, including the first plastic surgeon’s statement concerning the diagnosis and proposed treatment, a photograph intended to illustrate the patient’s condition and the surgical report on the procedure performed. The medical consultant advised that the medical necessity of the procedure has not been established by the surgeon in that the degree of eyelid drooping causing vision impairment has not been addressed, nor has the expected degree of improvement in vision been discussed. Blepharoplasty is customarily performed for cosmetic improvement. Specific documentation by the medical specialist has not been provided to establish its medical necessity; therefore, the Employee’s spouse’s plastic surgery is not covered under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not responsible for providing health benefits coverage for the Employee’s spouse’s eye surgery.