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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 88-423 – January 21, 1992

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 laboratory tests under the terms of the Employer Benefit Plan.

Background Facts

The Employee’s spouse was seen at a family practice office for multiple complaints, including hip pains, index finger pain, weight gain, vaginal discharge, a cold and sore throat. The physician ordered an ultrasound image of the uterus, x-rays and laboratory tests, including a pathology panel (a series of tests). The Employer paid all charges pertaining to this visit, except the charge for the pathology panel.

Dispute

Is the Employer required to provide benefits under the Employer Benefit Plan for the pathology panel of laboratory tests?

Positions of the Parties

Position of the Employee: The Employer is required to pay the charge for the pathology panel of laboratory tests because such tests are covered under the Employer Benefit Plan.

Position of the Employer: The Employer is not required to pay the charge for the pathology panel of tests because the tests were non-specific, routine screening that did not diagnose or treat a definite condition, illness or injury.

Pertinent Provisions

Article III. A. (3)(j) of the Employer Benefit Plan states:

(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.

Discussion

Under Article III. A. (3)(j) of the Employer’s Plan, benefits are provided for laboratory tests and x-ray services performed in a licensed laboratory when they have been ordered by a physician for diagnosis or treatment of a definite condition, illness or injury. Furthermore, laboratory tests and x-rays ordered in connection with a routine physical examination are excluded unless considered medically necessary by a physician.

A Funds medical consultant reviewed this file, which includes a detailed record of the patient’s office visit. The consultant notes that the physicians’ current procedural terminology (CPT) code for the pathology panel in question denotes an “executive profile”, which is a comprehensive series of tests usually performed as part of a physical examination. The consultant has advised that the medical notes for the visit in question make no mention of the need for the pathology panel of tests, the reason it was ordered, or the fact that such a panel of tests was ordered or performed. The consultant is of the opinion that the pathology panel in question was not medically necessary for the diagnosis or treatment of a definite condition, illness or injury. Therefore, the Employer is not required to pay the charges for the pathology panel performed in this case.

Opinion of the Trustees

The Employer is not required to pay the charge for the pathology panel of laboratory tests performed in this case.