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OPINION OF TRUSTEES
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In Re
Complainants: Employee
Respondent: Employer
ROD Case No: 88-630 – November 4, 1992
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; Elliott A. Segal, 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 diagnostic blood pressure monitoring under the terms of the Employer Benefit Plan.
Background Facts
After experiencing fluctuating blood pressure, the Employee was advised by his physician that it would be necessary to monitor his blood pressure for 24 hours to evaluate the fluctuations and determine a proper course of action. On May 17, 1991, the physician fitted the Employee with a blood pressure monitor, which he was to wear for 24 hours and then return to the physician’s office.
The Employer denied benefits for the blood pressure monitoring, stating that the service provided was durable medical equipment and that coverage criteria for the medical necessity of durable medical equipment were not satisfied in this case.
Dispute
Is the Employer required to provide benefits for the blood pressure monitoring services rendered to the Employee on May 17, 1991?
Positions of the Parties
Position of the Pensioner: The Employer is required to provide benefits for the blood pressure monitoring services rendered to the Employee on May 17, 1991 because the physician felt the services were necessary and the Employee had no reason to believe that the information was not pertinent or that an alternative method existed for collecting the data.
Position of the Employer: The Employer is not required to provide benefits for the blood pressure monitor provided to the Employee on May 17, 1991 because durable medical equipment must meet criteria of medical necessity for the treatment of an illness or injury and the blood pressure monitor does not treat the Employee’s medical condition.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit states 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….
Article III. A. (3), Section (o) 2. and A. (6)(d) of the Employer Benefit Plan provide:
(3) Physicians’ Services and Other Primary Care
(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.
(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 to Article III of the Employer Benefit Plan states that covered services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care.
Article III. A. (3)(o) 2. of the Employer Benefit Plan provides that “[b]enefits 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.”
Article III. A. (6)(d) of the Employer Benefit Plan provides for the rental or purchase of medical equipment for home use when determined to be medically necessary by a physician.
The Employer cited Article III. A. (6)(d) of the Plan in its denial of benefits in this case, basing its decision on the perception that the charges were for the rental or purchase of a blood pressure monitor. A Funds’ medical consultant has reviewed the information presented in the case and has advised that the charges in question were for a diagnostic procedure using a piece of equipment not owned or rented by the Employee, that the Employee wore to monitor his blood pressure over a 24-hour period. Therefore, the issue is not whether the Employee’s rental or purchase of a blood pressure monitor is covered and it is not appropriate to apply Article III. A. (6)(d) in this case. Further, the consultant is of the opinion that the diagnostic procedure of wearing the blood pressure monitor for 24 hours was medically reasonable and of value diagnostically to the patient and his physician. This case is distinguishable from ROD 88-466 (copy enclosed) in which the Trustees denied benefits for a blood pressure monitor as Durable Medical Equipment, purchased by the Employee. In that case, a medical consultant noted no documentation of unique needs of the patient that would justify the provision of benefits for the equipment purchase.
Because blood pressure monitoring was reasonable in this case for the diagnosis of the Employee’s illness, the Trustees conclude that the Employer is required to provide benefits for the services rendered to the Employee on May 17, 1991.
Opinion of the Trustees
The Employer is required to provide benefits for the blood pressure monitoring services provided to the Employee on May 17, 1991.