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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-655 – 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 benefits for polysomnography tests under the terms of the Employer Benefit Plan.
Background Facts
On August 7 and August 8, 1991, the Employee’s spouse underwent polysomnography testing ordered by her physician for the evaluation of her medical condition, which included a large goiter due to hypothyroidism, difficulty swallowing, muscle cramps, fatigue, and shortness of breath.
The Employer provided benefits for the polysomnography testing on August 7, 1991, but denied benefits for the testing on August 8, 1991, stating that testing on the second night was not medically necessary.
Dispute
Is the Employer required to provide benefits for the Employee’s spouse’s polysomnography testing on August 8, 1991?
Positions of the Parties
Position of the Employee: The Employee asks whether the Employer is required to provide benefits for the polysomnography testing provided for his wife on August 8, 1991.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s wife’s polysomnography testing on August 8, 1991 because it was not medically necessary.
Pertinent Provisions
Article III. A. (3)(o) 2. of the Employer Benefit Plan states:
(o) Primary 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.
Discussion
Article III. A. (3)(o) 2. of the Employer Benefit Plan provides coverage for diagnostic procedures when medically necessary. A Funds’ medical consultant has reviewed the medical records in this case to include a letter from the Employee’s spouse’s physician dated February 27, 1992 and reports of polysomnography tests performed on August 7 and August 8, 1991. The consultant has advised that the information he has reviewed documents that the patient has a large goiter with difficulty swallowing and a history of muscle cramps, fatigue, and complaints of shortness of breath. The consultant has stated that, although there is not strong clinical documentation of the need for polysomnography testing, there is a consistent and plausible explanation to use this test to rule out a cause of the patient’s symptoms.
In the consultant’s opinion, the medical record supports clinical symptoms that can be attributed to sleep apnea and the approval of the first night of polysomnography testing requires approval of the second night of testing in that Continuous Positive Airway Pressure (CPAP), a possible treatment, was tried on the second night to determine its effectiveness. Because the polysomnography testing on the second night was medically necessary to determine the effectiveness of a possible treatment, the Trustees conclude that the Employee’s spouse’s polysomnography testing in this case is covered under the under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is required to provide benefits for the Employee’s spouse’s polysomnography testing on August 8, 1991.