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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-668 – July 8, 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 surgery under the terms of the Employer Benefit Plan.
Background Facts
In March, 1980, the Employee underwent a septoplasty (reconstruction of the septum, or central cartilage of the nose) to alleviate difficulty in breathing. The procedure markedly improved his condition, but he has again begun to experience difficulty in breathing through the nasal passage. In July, 1992, the Employee’s physician recommended that he undergo the surgical procedures of septoplasty, partial turbinectomy (removal of a bony plate in the nasal passage), and tonsillar uvulopalatopharyngoplasty (an operation in the area between the mouth and larynx) for improvement in nasal breathing, as well as alleviation of related problems with severe snoring and mild sleep apnea. In addition, the physician stated that the Employee has a very droopy nose that falls over his nasal passage and further contributes to the problem. To correct the droopy nose, the physician has recommended that a surgical nasal tip elevation be performed for breathing purposes at the same time as the other procedures.
The Employee requested prior authorization from the Employer for the surgical procedures. The Employee’s physician submitted a letter of medical necessity in support of the procedures. The results of a study performed by another physician at a sleep disorders center were also submitted. The physician who performed this study reported in June 1992 that the Employee had snoring with little significant apnea or hypopnea. He recommended directing efforts at improving nasal resistance and deferring the uvulopalatopharyngoplasty until the benefits of the nasal procedure can be ascertained. A third physician submitted an opinion, dated October 1, 1992, supporting the patient’s need for nasal surgery and recommending further evaluation of the sleep apnea problem with the possibility of uvulopalatopharyngoplasty. This physician stated that the Employee should at least undergo a tonsillectomy, based on a high frequency of sore throats.
The Employer gave approval for the septoplasty and turbinectomy. The Employer did not provide approval for the tip elevation of the nose on the grounds that the procedure is cosmetic nearly all of the time, nor for the uvulopalatopharyngoplasty, because the only sleep evaluation performed indicated no significant apnea or hypopnea. In addition, the Employer requested that photographs of the Employee and information from any additional testing be forwarded for review, but neither was received.
Dispute
Is the Employer required to provide benefits for a nasal tip elevation and uvulopalatopharyngoplasty proposed for the Employee?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s proposed nasal tip elevation and uvulopalatopharyngoplasty because these surgical procedures are necessary to correct a life-threatening condition.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s proposed nasal tip elevation and uvulopalatopharyngoplasty because the procedures are not medically appropriate, based on the medical information submitted.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan 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, 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. (3) (a), (f) and (p) 9. state:
(3) Physicians’ Services and Other Primary Care
(a) Surgical Benefits
Benefits are provided for surgical services essential to a Beneficiary’s care consisting of operative and cutting procedure (including the usual and necessary post-operative care) for treatment of illnesses, injuries, fractures or dislocations, which are performed either in or out of a hospital by a physician.
(f) Surgical Services Limitations
Benefits are not provided for certain surgical services without prior approval of the Plan Administrator. Such services include, but are not limited to, the following:
Plastic surgery, including mammoplasty
Reduction mammoplasty
Intestinal bypass for obesity
Gastric bypass for obesity
Cerebellar implants
Dorsal stimulator implants
Prosthesis for cleft palate if not covered by crippled children services
Organ transplants
(p) Services Not Covered
9. Cosmetic surgery, unless pertaining to surgical scars or to correct results of an accidental injury or birth defects.
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, or are otherwise provided for in the Plan. Article III. A. (3) (a) states that benefits are provided for surgical services essential for a Beneficiary’s care for the treatment of illnesses, injuries, fractures or dislocations. Article III. A. (3) (f) of the Plan states that benefits are not provided for certain surgical services such as plastic surgery without prior approval of the Plan Administrator. Article III. A. (3) 9. states that cosmetic surgery is not covered unless it is performed to correct surgical scars or to correct results of an accidental injury or birth defects.
A Funds’ medical consultant has reviewed the information submitted in this case, including letters and medical records from the Employee’s physicians and a sleep disorders evaluation. The consultant has advised that, given the information available, he is of the opinion that the septoplasty and turbinectomy have been documented to be medically necessary, but the uvulopalatopharyngoplasty and surgical nasal tip elevation have not been adequately documented as medically necessary.
The Employer has already given approval for the septoplasty and turbinectomy. Because the medical necessity for the uvulopalatopharyngoplasty and the nasal tip elevation surgery have not been established, the Trustees conclude that the Employer is not required to provide prior approval for these surgical procedures.
Opinion of the Trustees
The Employer is not required to provide benefits for the Employee’s proposed uvulopalatopharyngoplasty and nasal tip elevation.