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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 88-651 – September 28, 1993
Board of Trustees: Michael H. Holland, Chairman; Thomas F. Connors, Trustee;
Marty D. Hudson, Trustee; Robert T. Wallace, Trustee.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for an adjustable hospital bed under the terms of the Employer Benefit Plan.
Background Facts
On November 19, 1991 the Pensioner ordered a twin size adjustable bed which was delivered to his home and assembled on December 12, 1991. The electric adjustable bed came with a “heat sheet” and a two-speed massage feature. The total cost was $995.00, which the Pensioner paid in full at the time of delivery.
On January 30, 1992 the Pensioner’s attending physician wrote a letter to the Employer’s claims administrator citing several conditions necessitating the Pensioner’s purchase of the adjustable bed. The reasons were: 1) a circulatory problem requiring the elevation of his extremities. The Pensioner has had three vein ligation and stripping procedures due to varicose veins in both legs. He is currently on circulatory medication for this condition. Additionally, he has had difficulty with swelling of the legs and phlebitis. The physician further states that the Pensioner derives some relief with elevation of his feet and legs during sleep; 2) he has pinched nerves of the cervical spine and elevation of his head during sleep somewhat relieves the pain in his neck; 3) he has chronic bronchitis; and elevation of the head during sleep aids in lessening his difficulty in breathing and helps with the expectoration of mucous; additionally, 4) he sustained a slight right-side stroke approximately three years ago.
On March 20, 1992 the Pensioner’s chiropractor wrote a letter citing chronic strains and sprains of the cervical and lumbar areas as conditions that would benefit from the added support given by an adjustable bed.
The Pensioner was notified by the Employer’s claims administrator of their denial of benefits for the adjustable bed on January 13, 1992, and February 13, 1992. The Pensioner appealed the denial, and on March 10, 1992 and April 30, 1992 the Employer’s claims administrator notified the Pensioner that they were upholding their original denial of benefits for the adjustable bed. The Employer’s claims administrator stated that hospital beds are normally considered eligible for those individuals diagnosed as completely disabled and bedridden, and that after several reviews, they had determined that the purchase of an adjustable bed for the treatment of circulatory problems, pinched nerves in the cervical spine, phlebitis, or chronic bronchitis did not meet the Plan’s definition of medical necessity and, therefore, would not be a covered benefit under the terms of the Employer Benefit Plan.
Dispute
Is the Employer required to provide benefits for the adjustable bed purchased by the Pensioner?
Positions of the Parties
Position of the Pensioner: The Employer is required to provide benefits for the adjustable bed because it helps alleviate the symptoms of several of the Pensioner’s medical conditions, and it was recommended by a physician and a chiropractor.
Position of the Employer: The Employer is not required to provide benefits for the Pensioner’s purchase of an adjustable bed because it does not meet the criteria to be considered medically necessary. Additionally, the bed would
be useful to anyone in the absence of an illness or injury, and it is a comfort or convenience item that is excluded from coverage under the Employer Benefit Plan.
Pertinent Provisions
The Introduction to Article III states in pertinent part:
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…
Article III. A. (6)(d) of the 1984 Employer Benefit Plan states:
(d) Medical Equipment
Benefits are provided for rental or, where appropriate, purchase of medical equipment suitable for home use when determined to be necessary by a physician.
Q&A 81-38 states in pertinent part:
Subject: Medical Equipment and Supplies
References:Amended 1950 & 1974 Benefit Plans & Trust, Article III. Section A. (6)(d) and (e), and A. (7) (a) and (d)
Question:
What medical equipment and supplies are covered under the Plan?
Answer:
A. Under the Home Health Services and Equipment provision, benefits are provided for the rental and, where appropriate as determined by the Plan Administrator, purchase of medical equipment and supplies (including items essential to the effective use of the equipment) suitable for home use when determined to be medically necessary by a physician. These supplies and equipment include, but are not limited to, the following:
1. Durable Medical Equipment (DME) which (a) can withstand use (i.e., could normally be rented), (b) is primarily and customarily used to service a medical purpose, (c) generally is not useful to a person in the absence of an illness or injury, and (d) is appropriate for use in the home. Examples of covered DME items are canes, commodes, and other safety bathroom equipment, home dialysis equipment, hospital beds and mattresses, iron lungs, orthopedic frames and traction devices, oxygen tents, patient lifts, respirators, vaporizers, walkers and wheel chairs…
C. Items of a convenience nature or those that do not require professional judgment, recommendations or instructions to purchase or to use are not covered benefits……
Discussion
The Introduction to 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 and which are given at the appropriate level of care. 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. (6)(d) of the Employer Benefit Plan, benefits are provided for medical equipment suitable for home use when determined by a physician to be medically necessary. Q&A 81-38 states that covered medical equipment includes Durable Medical Equipment (DME) which (a) can withstand use (i.e., could normally be rented), (b) is primarily and customarily used to serve a medical purpose, (c) generally is not useful to a person in the absence of an illness or injury, and (d) is appropriate for use in the home. Q&A 81-38 further stipulates that items of a convenience nature or those that do not require professional judgment, recommendations or instructions to purchase or use are not covered benefits.
Neither the Pensioner’s physician nor the chiropractor has established a medical condition that would necessitate the use of the adjustable bed. The primary purpose of the type of adjustable bed purchased by the Pensioner is not medical in nature. While the Pensioner may derive a therapeutic benefit from the use of the bed, it is generally used for relaxation and comfort purposes in the absence of an illness or injury.
A Funds’ medical consultant has reviewed this file to include letters from the Employee’s attending physician and chiropractor. The consultant noted that there was no information in the file concerning the severity of any of the medical conditions for which the bed was prescribed, nor is there documen-tation that the Employee was bedridden. The consultant further advises that adjustable beds are a consideration for patients where severe disabling conditions cause them to be bedridden. In the consultant’s opinion there is inadequate medical documentation to medically justify an adjustable bed under the terms of the Employer Benefit Plan.
Therefore, the Trustees conclude that the adjustable bed in question does not meet the definition of durable medical equipment which may be covered under the Employer Benefit Plan. In this, the circumstances of this case are similar to those of ROD 88-385 (copy enclosed herein). Accordingly, the Employer is not required to provide benefits for the Pensioner’s adjustable bed.
Opinion of the Trustees
The Employer is not required to provide benefits for the Pensioner’s purchase of an adjustable bed.