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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-008 – August 30, 1988
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 payment of health benefits for the prescription drug Kenalog-10 when used in the treatment of alopecia areata.
Background Facts
The Employee’s spouse visited a dermatologist on December 29, 1987 and January 29, 1988 for the treatment of alopecia areata (an auto-immune disease which causes a sudden loss of hair in circumscribed patches accompanied by little or no inflammation). The physician treated one area of alopecia areata measuring 5 x 6 cm on her scalp during the first visit and three areas measuring 1 x 1 cm, 1.4 x 1 cm and 2 x 2 cm on her second visit with multiple intralesional injections of triamcinolone acetonide in suspension (brand name: Kenalog-10), a corticosteroid. He has stated that alopecia areata is not a cosmetic disorder but a treatable medical illness. The physician states that the Employee’s spouse’s hair grew back in the treated areas.
The Employer denied the charges for the physician office visits and treatments because the treatment of alopecia areata by intralesional injections of steroids is experimental in nature. The Employer further states that such injections are not generally accepted by the medical profession as a treatment of proven value or usefulness.
Dispute
Is the Employer responsible for providing benefits for the Employee’s spouse’s treatment of alopecia areata by intralesional injections of Kenalog-10?
Positions of the Parties
Position of the Employee: The Employer is responsible for providing benefits for the treatment of the Employee’s spouse’s alopecia areata by intralesional injections of Kenalog-10 because it was medically necessary for the treatment of her illness.
Position of the Employer: The Employer is not responsible for providing benefits for the treatment of the Employee’s spouse’s alopecia areata by intralesional injections of Kenalog-10 because such treatment is experimental in nature.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states:
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan. In determining questions of reasonableness and necessity, due consideration will be given to the customary practices of physicians in the community where the service is provided. Services which are not reasonable and necessary shall include, but are not limited to the following: procedures which are of unproven value or of questionable current usefulness; procedures which tend to be redundant when performed in combination with other procedures; diagnostic procedures which are unlikely to provide a physician with additional information when they are used repeatedly; procedures which are not ordered by a physician or which are not documented in timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care. Covered services that are medically necessary will continue to be provided, and accordingly this paragraph shall not be construed to detract from plan coverage or eligibility as described in this Article III.
Article III. A. (3)(h) of the Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care
(h) Home, Clinic, and Office Visits
Benefits are provided for services rendered to a Beneficiary at home, in a clinic (including the outpatient department of a hospital) or in the physician’s office for the treatment of illnesses or injuries, if provided by a physician.
Article III. A. (11) (a) 24. of the Employer Benefit Plan states:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the 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.
Discussion
Article III. A. (3)(h) of the Employer Benefit Plan provides benefits for services rendered to a beneficiary in the physician’s office for the treatment of illnesses or injuries, if provided by a physician. The Introduction to Article III of the Employer Benefit Plan limits covered services to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care or are otherwise provided for in the Plan. The Introduction further states that services which are not reasonable and necessary shall include procedures which are of unproven value or of questionable current usefulness. In addition, Article III. A. (11) (a) 24. of the Plan excludes benefits for treatment with new technological medical devices and therapy which are experimental in nature.
The Employer has stated that the services rendered the Employee’s spouse are not covered benefits under the Plan because treatment of alopecia areata by intralesional injections of steroids is experimental and is not generally accepted by the medical profession as a treatment of proven value or usefulness.
The American Academy of Dermatology, a medical specialty society of board certified dermatologists is the recognized authority on the diagnosis and treatment of skin diseases. The Academy referred Funds’ staff to a physician and clinical professor of dermatology who is one of the Academy’s experts in the treatment of alopecia areata. The physician advised that treatment by intralesional injections of corticosteroids is recognized by the medical profession as the accepted treatment for alopecia areata, a disease process. The physician further stated that such treatment is not experimental nor is it cosmetic, since it is a dermatological condition that is being treated and not the hair loss.
A Funds’ medical consultant has also reviewed this case and concurs that alopecia areata is a recognized dermatological condition that causes patchy hair loss and is reversible with proper medical intervention. He further stated that the treatment provided the Employee’s spouse was medically necessary and that the intralesional injection of steroids, as provided in this case, is a standard, accepted and approved treatment for alopecia areata.
Inasmuch as the Employee’s spouse received treatment by her physician for a recognized medical illness, and such treatment is not considered to be experimental, the Employer is responsible for providing benefits for such treatment, consistent with Article III. A. (3)(h) of the Plan.
Opinion of the Trustees
The Employer is responsible for providing benefits for the treatment of the Employee’s spouse’s alopecia areata by intralesional injections of Kenalog-10.