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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-349 – May 8, 1991
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 a cholesterol screening test under the terms of the Employer Benefit Plan.
Background Facts
On April 16, 1990, the Employee was seen by a physician for concerns about a mole and knee problem. The physician recommended that the 44-year-old Employee undergo a cholesterol screening test as it was her first visit to the office and she had never had her cholesterol level measured before. The Employee contends that the test was medically necessary because she has a family history of cholesterol problems. According to a statement from the Employee’s physician dated November 12, 1990, the physician ordered the test because recent literature and government reports indicate that every adult should be screened for elevated cholesterol. The physician also stated that the Employee’s cholesterol level was elevated and she is now on a cholesterol-lowering diet.
The Employer denied benefits for the cholesterol screening test performed on the Employee.
Dispute
Is the Employer required to provide benefits for the cholesterol screening test performed on the Employee on April 16, 1990?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the cholesterol screening test because the test was ordered by the Employee’s physician and was medically necessary given her family history of cholesterol problems.
Position of the Employer: The Employer is not required to provide benefits for the cholesterol screening test because it was not performed to diagnose or treat a definite condition, illness or injury and therefore it is not a covered benefit under the Employer Benefit Plan.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan provides in pertinent part:
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. (3)(j) and (3)(o) 2. of the Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care
(j) Laboratory Tests and X-rays
Benefits will be provided for laboratory tests and x-rays performed in a licensed laboratory when ordered by a physician for diagnosis or treatment of a definite condition, illness or injury.
Such benefits will not cover laboratory tests and x-rays ordered in connection with a routine physical examination, unless the examination is considered medically necessary by a physician.
(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
The Introduction to Article III of the Employer Benefit Plan limits covered services to those 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 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. Under Article III. A. (3)(j) of the Plan, benefits are provided for laboratory tests and x-rays when ordered by a physician for diagnosis or treatment of a definite condition, illness or injury. Under Article III. A. (3)(o)2. of the Plan, 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.
In this case, the Employee sought medical evaluation and treatment for a mole and a knee problem. The physician has stated that he ordered a cholesterol test in connection with his examination of the Employee because recent literature and government reports indicate that every adult should be screened for elevated cholesterol. A Funds’ medical consultant has reviewed the information submitted in this case and has advised that the cholesterol test performed in this case was a screening examination that was not medically indicated for the Employee’s complaints. Because the medical necessity of the test performed in this case has not been established, the Employer is not required to provide benefits for it under the terms of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for the cholesterol screening test performed on the Employee on April 16, 1990.