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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No.: 88-652 – September 28, 1993
Board of Trustees: Michael H. Holland, Chairman; Thomas F. Connors, Trustee; Marty D. Hudson, Trustee; Robert T. Wallace, Trustee.
Pursuant to the terms of the collective bargaining agreement, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for a light box as durable medical equipment under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s daughter was diagnosed with recurrent major depressions with a seasonal pattern, also known as Seasonal Affective Disorder (SAD). The Employee’s daughter’s psychiatrist prescribed a light box in order to perform phototherapy, a treatment using bright artificial light. He believes that bright (2,500 to 10,000 lux) light has antidepressant effects. The psychiatrist states that studies in Europe and the United States have shown that treatment with bright environmental light (phototherapy) has been effective in treating SAD.
On March 25, 1992 the Employee’s daughter purchased the light box for $490.00 The Employer denied the charges for the light box as not medically appropriate in the treatment of this disease. The Employer notes that light boxes have been approved for the treatment of jaundice or skin disorders, but they have not been proven useful in the absence of a medical illness. The Employer states that Seasonal Affective Disorder is not considered a medical illness, rather it is a condition which requires psychotherapy rather than therapeutic treatment.
Dispute
Is the Employer required to provide benefits for the purchase of a light box to treat the Employee’s daughter’s Seasonal Affective Disorder?
Position of the Parties
Position of the Employee: The Employer is required to provide benefits for the purchase of a light box to perform phototherapy on the Employee’s daughter since the light box was prescribed by a physician and has been found to be beneficial in treating SAD.
Position of the Employer: The Employer is not required to provide benefits for the purchase of a light box for the Employee’s daughter since this type of therapy has not been medically proven to be useful in the absence of a medical illness. Since the diagnosis is not for a medical illness, the condition requires the use of psychotherapy rather than therapeutic treatment.
Pertinent Provisions
The Introduction to Article III 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 a timely fashion in the patient’s medical records; procedures which can be performed with equal efficacy 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.(6)(d) states:
(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.
Article III.A.(11)(a) 24. states:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
24. Charges for treatment with new technological devices and therapy which are experimental in nature.
Discussion
Article III provides benefits for 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 under 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 the Plan. The Introduction to Article III further states that services which are of unproven value or of questionable current usefulness are not eligible under the Plan.
Article III.A.(6)(d) provides benefits for the rental, or purchase when appropriate, of medical equipment suitable for home use when determined to be medically necessary by a physician.
The U.S. Food and Drug Administration states that the use of a light box in treatment of SAD is not approved for use at this time. Funds staff have contacted several major health insurance carriers concerning their provision of benefits for this type of treatment, and have found none that would provide benefits.
A Funds’ medical consultant has reviewed the information submitted in this case, including a letter from the treating psychiatrist as well as medical literature provided by the light box manufacturer, and has concluded that there is inadequate medical documentation of the patient’s condition, that there is no clinical evidence that treatment with a light box would be more beneficial for the Employee’s daughter’s SAD than more conservative therapy, and that light therapy has not been accepted as a proven treatment for SAD.
Article III.A.(11)(a) 24. excludes benefits for treatment with new technological medical devices and therapy which is experimental in nature. The Trustees conclude that the Employer is not required to provide benefits for the purchase of the light box in the treatment of the Employee’s daughter’s Seasonal Affective Disorder.
Opinion of the Trustees
The Employer is not required to provide benefits for the Employee’s daughter’s light box purchased on March 25, 1992.