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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 07-0061 – September 29, 2011
Trustees: Micheal W. Buckner, Daniel L. Fassio, Morris D. Feibusch, and Michael
H. Holland.
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
Complainant’s son was born prematurely on May 14, 2010, at 35 weeks and four days’ gestation and then treated for 26 days following his birth for moderately severe respiratory problems. In the fall of 2010, Complainant’s son underwent treatment for acute pulmonary bronchiolitis with oxygen, oral corticosteroids and bronchodilators and then received four injections of Synagis between November 2010 and February 2011 for the prevention of respiratory syncytial virus (“RSV”). Respondent determined that the injections were not medically necessary and denied coverage.
Dispute
Were the Synagis injections provided to Complainant’s son between November 2010 and February 2011 medically necessary and, therefore, covered under the terms of the Employer Benefit Plan (the “Plan”)?
Positions of the Parties
Position of the Complainant: The Synagis injections were medically necessary due to the child’s medical history and are, therefore, covered under the terms of the Plan.
Position of the Respondent: The Synagis injections were not medically necessary and are, therefore, not covered under the terms of the Plan.
Pertinent Provisions
The preamble to Article III of the Plan states, in pertinent part:
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 timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care.
Discussion
Article III of the Plan covers only those services which are medically necessary. The Funds’ Medical Director reviewed the medical records submitted in this ROD and determined that, inasmuch as Complainant’s son received treatment for chronic lung disease with oxygen, chronic corticosteroids, and bronchodilators within 6 months prior to RSV season, “the 4 Synagis injections given to [Complainant’s son] were medically necessary and a covered benefit of the Employer Benefit Plan.”
Opinion of the Trustees
The Synagis injections provided to Complainant’s son between November 2010 and February 2011 were medically necessary and, therefore, covered under the terms of the Plan.