_____________________________________________________________________________
OPINION OF TRUSTEES
_____________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-117 – November 20, 1989
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, 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 a diagnostic procedure under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse has metastatic carcinoma of the thyroid. In 1985 and 1988, she had surgery to remove cancerous nodules on her neck. Her physician states that the results of her subsequent blood work showed persistent elevation of serum calcitonin, which suggested that her tumor might have spread. However, computerized tomography (“CT”) scans, which might have provided additional evidence, were inconclusive. Consequently, the Employee’s spouse’s physician, a specialist in endocrinology, ordered a CT scan and magnetic resonance imagings (“MRI”) of the neck and chest to provide additional information.
The Employer provided coverage for the MRI of the neck. However, the Employer denied the charges for the MRI of the chest, stating that only MRIs of the brain and spinal cord are covered under its benefit plan.
Dispute
Is the Employer required to provide health benefits for the Employee’s spouse’s chest MRI?
Positions of the Parties
Position of the Employee: The Employer is required to provide health benefits for the Employee’s spouse’s chest MRI because it is a covered benefit under the Employer Benefit Plan.
Position of the Employer: The Employer is not required to provide health benefits for the Employee’s spouse’s chest MRI because only MRIs of the brain and spinal cord are covered under its benefit plan.
Pertinent Provisions
Article III. A. (3)(o) 2. of the Employer Benefit Plan states:
(o) Primary Medical Care – Miscellaneous
2. Benefits are provided for immunizations, allergy desensitization injections, pap smears, screening for hypertension and diabetes, and examinations for cancer, blindness, deafness, and other screening and diagnostic procedures when medically necessary.
Discussion
In this case, the Employer provided coverage for the Employee’s spouse’s MRI of the neck. The Employer contends that only MRIs of the brain and spinal cord are covered under its benefit plan. Consequently, it denied benefits for the Employee’s spouse’s MRI of the chest performed on September 26, 1988.
Under Article III. A. (3)(o) 2. of the Employer Benefit Plan, benefits are provided for examinations for cancer and other screening and diagnostic procedures when medically necessary. A chest MRI can be useful for the diagnosis of thyroid cancer or lung cancer and may be covered under Article III. A. (3)(o) 2. when medically necessary.
A Funds’ medical consultant has reviewed this file and advises that the Employee’s spouse has a history of medullary carcinoma of the thyroid with persistent elevation of serum calcitonin levels, which indicates the possibility of a spread of the medullary tumor. The consultant advises that the added resolution of the MRI along the thoracic spine and mediastinal areas of the chest could detect tumors not seen on the prior CT scans. The consultant notes that the patient’s primary tumor was located in the neck and developed in a gland which has its embryonic origin in tie mediastinum. According to the consultant, it was reasonable to extend the MRI of the neck to the chest because the thoracic spine and mediastinal structures are similar in density and are a continuation of those examined by the MRI of the neck. For these reasons, the consultant is of the opinion that the MRI of the chest in this particular case was a medically necessary diagnostic procedure. Consequently, the Employer’ is required to provide benefits pursuant to Article III. A. (3)(o) 2. of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is required to provide benefits for the Employee’s spouse’s chest MRI performed on September 26, 1988.