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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-401 – September 24, 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 benefits for co-dependency therapy and family counseling under the terms of the Employer Benefit Plan.
Background Facts
The Employee participated in a two-week outpatient treatment program for family members of alcoholics. She attended the program from 9 a.m. to 4:30 p.m., Monday through Friday from June 19, 1989 through June 30, 1989. According to the information submitted in this case, the program uses a multidisciplinary approach to diagnose and treat the medical, psychological, social and spiritual aspects of alcoholism in the family. The Employee was involved daily in counseling, group therapy and lectures which focused on the problems of chemical dependency in the family and living with it. Upon completion of the program, the Employee continued to see a therapist affiliated with the program and attended four family counseling sessions in July, August and September 1989.
The Employer has denied benefits for the two-week co-dependency therapy program and the family counseling sessions.
Dispute
Is the Employer required to provide benefits for the Employee’s co-dependency therapy and family counseling sessions?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the co-dependency therapy and family counseling because the Employee was being treated for psychological problems.
Position of the Employer: The Employer is not required to provide benefits for the co-dependency therapy and family counseling because co-dependency is not a disease and the services in question were not provided nor required for the treatment of a medical condition.
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 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. (7)(f) of the Employer Benefit Plan states:
(7) Other Benefits
(f) Outpatient Mental Health, Alcoholism and Drug Addiction
Benefits are provided for:
Psychotherapy, psychological testing, counseling, group therapy and alcoholism or drug rehabilitative programs where free care sources are not available and when determined to be medically required by a physician.
Benefits are not-provided for:
1. Encounter and self-improvement group therapy.
2. Custodial care related to mental retardation and other mental deficiencies.
3. School related behavioral problems.
4. Services by private teachers.
5. Alcoholism and drug rehabilitation if an advance determination has not been made by the rehabilitation team that the Beneficiary is a good candidate for rehabilitation.
6. Alcoholism and drug rehabilitation programs not approved by Medicare.
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 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. Article III. A. (7)(f) of the Plan provides benefits for outpatient psychotherapy, psychological testing, counseling, group therapy and alcoholism or drug rehabilitative programs when free care sources are not available and when determined to be medically required by a physician.
In this case, the Employee participated in a two-week co-dependency therapy program and family counseling sessions. While a diagnosis of adjustment disorder with mixed emotional features was indicated on some of the records submitted, such diagnosis was not used in the billing submitted to the Employer’s insurance carrier. The diagnosis used on the billing was “health problems within the family” and this diagnosis is consistent with the treatment provided, which was designed for family members of alcoholics. A Funds’ medical consultant has reviewed the information submitted in this case and has advised that there is no medical documentation that the Employee required treatment for a disease or illness. The consultant also noted that the diagnosis code used by the provider indicates health problems within the family and designates conditions other than an illness or injury. For these reasons, the consultant advised that the services rendered to the Employee beginning in June 1989 were not
medically required for the treatment of an illness or injury. Inasmuch as the Employee’s co-dependency therapy and family counseling services were not medically required for the treatment of an illness or injury, the Employer is not required to provide benefits for those services.
Opinion of the Trustees
The Employer is not required to provide benefits for the Employee’s co-dependency therapy and family counseling sessions.