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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 84-261 – September 18, 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 benefits for a seat lift chair under the terms of the Employer Benefit Plan.
Background Facts
The Pensioner is being treated for severe rheumatoid arthritis of the hips, knees, and ankles. The arthritis has caused fusion of the Pensioner’s joints at the hips and right ankle. As part of the treatment program, the physician prescribed a seat lift chair (more commonly referred to as “seat lift”) to prevent bed or chair confinement, to prevent further fusion of the patient’s joints and to facilitate his mobility.
The seat lift was prescribed on May 29, 1985 on a rental basis with prospective purchase if the seat lift proved to be beneficial. The Employer refused to pay any benefits for it on the grounds that seat lift chairs are not covered under the Plan because they are not primarily and customarily used to serve a medical purpose and they would be useful in the absence of an illness or injury. The medical equipment company removed the seat lift from the Pensioner’s home in July 1986 due to lack of payment by the Employer’s insurance carrier.
Dispute
Is the Employer responsible for paying benefits for the seat lift?
Position of the Parties
Position of the Employee: The Employee contends that since his arthritis prevents him from lifting himself out of a chair, the seat lift is medically necessary and therefore is covered under the Employer Benefit Plan.
Position of the Employer: The Employer contends that the seat lift chair is not covered under the Plan because the chair is not primarily and customarily used to serve a medical purpose and would be useful in the absence of an illness or injury.
Pertinent Provisions
Article III A. (6) (d) of the 1984 Employer Benefit Plan states:
(d) Medical Equipment
Benefits are provided for rental or, where appropriate, purchase of medical equipment suitable for home use when determined to be medically necessary by a physician.
Q and A #81-38 states:
Subject: Medical Equipment and Supplies
References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (6) (d) and (e), and A (7) (a) and (d)
Question:
What medical equipment and supplies are covered under the Plan?
Answer:
A. Under the Home Health Services and Equipment provision, benefits are provided for the rental and, where appropriate as determined by the Plan Administrator, purchase of medical equipment and supplies (including items essential to the effective use of the equipment) suitable for home use when determined to be medically necessary by a physician. These supplies and equipment include, but are not limited to, the following:
1. Durable Medical Equipment (DME) which (a) can withstand use (i.e., could normally be rented), (b) is primarily and customarily used to service a medical purpose, (c) generally is not useful to a person in the absence of an illness or injury, and (d) is appropriate for use in the home. Examples of covered DME items are canes, commodes and other safety bathroom equipment, home dialysis equipment, hospital beds and mattresses, iron lungs, orthopedic frames and traction devices, oxygen tents, patient lifts, respirators, vaporizers, walkers and wheel chairs.
2. Medical supplies necessary to maintain homebound or bedridden Beneficiaries. Examples of covered supplies are enema supplies, disposable sheets and pads (also called “Chux” or “blue pads’), supplies for home management of open or draining wounds, heating pads (for therapeutic use only) and insulin needles and syringes.
3. Oxygen, as specified in Article III, Section A (6) (e).
Discussion
Article III A. (6)(d) of the Employer Benefit Plan provides benefits for medical equipment suitable for home use when determined to be medically necessary by a physician.
Q&A 81-38 states that covered equipment includes, “Durable Medical Equipment (DME) which (a) can withstand use (i.e., could normally be rented), (b) is primarily and customarily used to service a medical purpose, (c) generally is not useful to a person in the absence of an illness or injury, and (d) is appropriate for use in the home.” The seat lift chair rented for the Employee’s spouse meets all four criteria. First, it can withstand repeated use. Second, a seat lift is primarily and customarily used for a medical purpose–i.e., to assist mobility-impaired persons to sit and stand. Third, the lift function of the chair would not be useful for persons who do not have an illness or injury that causes impairment of mobility. Fourth, the seat lift can be safely operated without the assistance of professional personnel and is therefore suitable for home use.
Although an item of DME may meet the criteria outlined in Q&A 81-38, it is covered under Article III. A. (6)(d) of the Employer Benefit Plan only if it is medically necessary for the treatment of an illness or injury. In ROD 84-135 (copy enclosed), the Trustees concluded that the prescribed seat lift was covered under the Plan because its medical necessity in that particular case had been established. Conversely, in ROD 84-219 (copy enclosed), the Trustees concluded that the prescribed seat lift was not covered under the Plan because its medical necessity in that case had not been established. The Medicare program has established five criteria that provide a useful framework for determining the medical necessity of a seat lift in a specific case. Those criteria are: 1) the patient is diagnosed as having severe arthritis of the hip or knee or a neuromuscular disease; 2) the patient can benefit therapeutically from use of the device; 3) the seat lift is included in the physician’s course of treatment; 4) the seat lift is likely to effect improvement, or arrest or retard deterioration in the patient’s condition; and 5) the severity of the condition is such that the alternative would be chair or bed confinement.
In this case, all five Medicare criteria have been met. First, the Pensioner has been diagnosed as having rheumatoid arthritis of such severity that it has caused fusion of the hips and right ankle. Second, the prescribing physician has stated that the Pensioner benefits therapeutically
from the seat lift chair by increasing mobility and aiding circulation. He stated that the Pensioner developed a decubitus ulcer (pressure sore) on his right hip after the seat lift was removed from
the home. Third, the seat lift was prescribed by the physician treating the Pensioner’s arthritis. Fourth, the physician has stated that the seat lift aids in retarding deterioration of the Pensioner’s condition by preventing further fusion of the joints. Fifth, the physician has stated that the seat lift prevents bed or chair confinement because the Pensioner is not able to get out of a chair independently. After reviewing the above information and the other clinical data, a Funds’ medical consultant concurred with the prescribing physician’s finding that in this case the seat lift is medically necessary for the treatment of the Pensioner’s arthritis.
The seat lift that was prescribed for the Pensioner is an item of durable medical equipment which may be covered under the Plan, and the Pensioner,s physician has established that it is medically necessary. Therefore, the seat lift chair is a covered benefit under the Employer Benefit Plan.
Opinion of the Trustees
Consistent with the terms of the Employer Benefit Plan, the Employer is responsible for providing benefits for the rental of the seat lift chair for the period of time (May 1985 through July 1986) the seat lift was in the Pensioner’s home and is also responsible for providing benefits for the continued use of a seat lift chair by the Pensioner pursuant to Plan provisions.