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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 98-026 – February 19, 2002

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 benefits under the terms of the Employer Benefit Plan.

Background Facts

The Complainant’s spouse has a history of chronic back, shoulder, and upper neck pain that has been associated with extremely large breasts. According to her consulting physician, drug therapy provided only temporary relief of her symptoms. The physician also noted that the Complainant’s spouse has been treated by different practitioners for several years with only temporary improvement of her symptoms.

The physician has recommended bilateral reduction mammoplasty (breast reduction surgery) to alleviate the patient’s symptoms of back, shoulder, and neck pain. The Employer denied the
Complainant’s request for prior approval of the surgery.

Dispute

Is the Employer required to provide benefits for the proposed reduction mammoplasty?

Positions of the Parties

Position of the Complainant: The Respondent is required to provide benefits for the bilateral reduction mammoplasty because it is medically necessary.

Position of the Respondent: The Respondent is not required to provide benefits for the proposed surgery because the reduction mammoplasty is only covered in connection with reconstruction following breast cancer surgery. The extenuating circumstances in this case do not warrant an exception to the exclusion under the Employer Benefit Plan. Moreover, the Respondent states that its position is supported by the following Trustee opinions: RODs 318, 81-551, 84-510 and 88-263.

Pertinent Provisions

The Introduction to Article III of the Employer Benefit Plan states in 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) and (f) of the Employer Benefit Plan 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 the 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 surgical procedures 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

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 to 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 including reduction mammoplasty without prior approval of the Plan Administrator.

A Funds’ medical consultant has reviewed the information submitted in this case and advises that prior approval for reduction mammoplasty would require medical documentation of an illness or injury which requires surgical intervention. The medical consultant notes that the medical documentation submitted by the consulting physician does not document a disease or injury directly related to the enlarged breasts of the Complainant’s spouse. According to the consultant, the documentation discusses potential muscular skeletal discomforts which can be due to multiple causes other than enlarged breasts. Consequently, based on the documentation submitted, the Respondent is not required to provide coverage for the Complainant’s spouse’s proposed bilateral reduction mammoplasty.

Opinion of the Trustees

The Respondent is not required to provide benefits for the Complainant’s spouse’s proposed bilateral reduction mammoplasty.