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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 88-128 – July 25, 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 coverage for chelation therapy for a Pensioner under the terms of the Employer Benefit Plan.
Background Facts
In September 1987, the Pensioner consulted a physician regarding possible chelation therapy (the removal of unwanted metal ions from the body) to treat his coronary artery disease. Upon examination and a review of the Pensioner’s medical records, the physician noted that the Pensioner suffered from coronary artery disease, degenerative joint and disc disease, probable immunologic dysfunction, hyperlipidemia, and probable toxic heavy metal exposure. The Pensioner received thirty chelation treatments between November 25, 1987 and July 6, 1988, in conjunction with a prescribed regimen of nutritional supplements. In addition, the Pensioner received physical therapy for low back pain, right shoulder and neck pain; the physician also recommended multiple lifestyle changes. The physician recommends that the Pensioner continue to receive a course of ten or more chelation treatments annually.
The Employer has denied benefits for the chelation therapy administered by the Pensioner’s physician.
Dispute
Is the Employer required to provide benefits for the chelation therapy administered to the Pensioner between November 25, 1987 and July 6, 1988?
Positions of the Parties
Position of the Pensioner: The Employer is required to provide benefits for the chelation therapy because it is a covered service under the Employer Benefit Plan.
Position of the Employer: The Employer is not required to provide benefits for the Pensioner’s chelation therapy because its medical necessity has not been established.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states:
ARTICLE III BENEFITS
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 be included, 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.
Discussion
The Introduction to Article III of the Employer Benefit Plan states that covered services are limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury.
In this case, the patient received thirty chelation treatments between November 25, 1987 and July 6, 1988; his physician is recommending that he continue to receive a course of ten or more chelation treatments annually. A Funds’ medical consultant has reviewed the information submitted in this file and advises that chelation therapy is used primarily for acute, time-limited treatment of acute heavy metal intoxication. According to the consultant, certain rare diseases such as Wilson’s disease, which involves an inability to metabolize copper, may be treated with
chelation therapy for prolonged periods of time. Chelation therapy is used by some practitioners to treat atherosclerosis and arteriosclerosis; however, the consultant advised that chelation therapy is not an accepted treatment for coronary artery disease in this country at this time.
The consultant is of the opinion that there is no evidence that the Pensioner has an illness or medical condition that requires prolonged chelation therapy as administered in this case. Therefore, the medical necessity of the chelation therapy administered to the Pensioner has not been established and the Employer is not responsible for providing benefits for the chelation therapy administered to the Pensioner.
Opinion of the Trustees
The Employer is not required to provide benefits for the chelation therapy administered to the Pensioner between November 25, 1987 and July 6, 1988.