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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-314 – November 28, 1990
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 benefits for a sheepskin for an Employee under the terms of the Employer Benefit Plan.
Background Facts
The Employee has an extensive history of back problems dating from a job-related Injury in 1985. The treatment provided by the Employee’s orthopedic surgeon progressed from conservative measures, including rest, heat, and a back brace, to surgery. On July 30, 1987, the Employee underwent surgery to correct a displaced vertebra with degenerative disk and to repair a leak in the outer membrane of his spinal cord. Due to a wound infection, the Employee was hospitalized again on August 9, 1987. Information provided by the orthopedic surgeon indicates that, during this hospitalization, a sheepskin was used on the Employee’s bed because he had developed pressure sores. Upon discharge, the attending physician, in the absence of the orthopedic surgeon, prescribed a sheepskin for the Employee’s use at home to prevent further development of pressure sores.
The Employer has denied benefits for the purchase of the sheepskin for home use.
Dispute
Is the Employer required to provide benefits for the sheepskin prescribed for the Employee’s home use?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the sheepskin because it is a necessary medical supply prescribed by the Employee’s physicians who had recommended extended periods of bedrest following his back surgery.
Position of the Employer: The Employer is not required to provide benefits for the sheepskin because the Employee’s physician has not established that the Employee was immobile or bedridden when he was discharged from the hospital. Therefore, the medical necessity for the sheepskin has not been established, and it is considered a convenience item which is not covered under the Employer Benefit Plan.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan provides:
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.
Article III. A. (6)(d) of the Employer Benefit Plan states:
(6) Home Health Services & Equipment
(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.
Discussion
The Introduction of Article III of the Employer Benefit Plan states that covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury. Article III. A. (6)(d) of the Employer Benefit Plan states that benefits are provided for the purchase of medical equipment suitable for home use when determined by a physician to be medically necessary. Q&A 81-38 (copy enclosed herein) states that under the Home Health Services and Equipment provision, benefits are provided for medical supplies including, but not limited to, those necessary to maintain homebound or bedridden Beneficiaries when determined to be medically necessary by a physician. Disposable sheets and pads, heating pads, and supplies for home management of open or draining wounds are examples of covered medical supplies.
The Employer contends that, without proper medical justification by the Employee’s physician, the sheepskin prescribed for the Employee is a convenience item which is not covered under the Employer Benefit Plan. The Employee’s attending physician and his orthopedic surgeon recommended that the Employee use a sheepskin to prevent and alleviate pressure sores from lying in bed for an extended period of time. A Funds’ medical consultant has reviewed the information presented in this case. The consultant has advised that the drainage of the Employee’s infected wound and the requirement for prolonged bed rest following surgery are likely to lead to decubitus ulcers if proper preventive measures are not taken. According to the consultant, although the Employee was improving at the time of discharge, he remained susceptible to complications from decubitus ulcers. The medical consultant has advised that the sheepskin was properly prescribed and medically necessary for the Employee’s home use in this case. Because the sheepskin prescribed in this case is medically necessary for the Employee’s home use, the Employer is required to provide benefits for the sheepskin.
Opinion of the Trustees
The Employer is required to provide benefits for the sheepskin prescribed for the Employee’s home use.