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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 93-047 – January 15, 2003
Trustees: A. Frank Dunham, Michael H. Holland, Marty D. Hudson and
Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for physical therapy under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse had low back pain radiating down her legs for several years. Records in the case indicate a diagnosis of lumbar arthritis. Her physician recommended physical therapy to improve her mobility and reduce the associated pain. According to the medical documentation submitted, the Employee’s spouse’s condition gradually improved over the course of therapy to a point where she was discharged to a home exercise program. The Employer provided benefits for the physical therapy for approximately one year. Benefits then were discontinued because the Employer’s agent stated that the treatments were being rendered by physical therapist aides. In dispute are benefits for 29 visits, all but one during the first three months of 1993.
Dispute
Is the Employer required to provide benefits for the Employee’s spouse’s 29 physical therapy treatments in 1993-1994?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the physical therapy sessions because they were rendered by licensed physical therapists.
Position of the Employer: The Employer is not required to provide benefits for the physical therapy sessions in dispute because they were rendered by physical therapist aides.
Pertinent Provisions
Article III A. (7) (b) states:
(7) Other Benefits
(b) Physical Therapy
Benefits are provided for physical therapy in a hospital, skilled nursing facility, treatment center, or in the Beneficiary’s home. Such therapy must be prescribed and supervised by a physician and administered by a licensed therapist. The physical therapy treatment must be justified on the basis of diagnosis, medical recommendation and attainment of maximum restoration.
Discussion
Article III A. (7) (b) provides benefits for physical therapy when it is prescribed and supervised by a physician and administered by a licensed therapist.
In this case, the Employee’s spouse received physical therapy for approximately a year for her low back pain, for which benefits were provided. Thereafter, the Employer denied benefits for 29 sessions, all but one occurring during the first three months of 1993, on the grounds that services were provided only by therapist aides. The submitted documentation includes progress notes prepared by physical therapy aides and physician’s progress reports prepared by the licensed physical therapist responsible for the Employee’s spouse’s treatment program. The documentation also demonstrates continuous improvement in her condition. The Employee’s spouse was discharged to a home exercise program.
Physical therapy services prescribed and supervised by a physician and administered by a licensed therapist are covered under the Employer Benefit Plan. Certified health care workers, such as physical therapy aides or nursing assistants, may assist in the treatment regimen as long as they are under the supervision of licensed personnel. In this case, all of the therapy was under the supervision of an attending physician. Therefore, consistent with the provisions of the Employer Benefit Plan, the Employer is required to provide benefits for the Employee’s spouse’s 29 physical therapy sessions.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is required to provide benefits for the Employee’s spouse’s 29 physical therapy sessions.