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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-116 – June 27, 1989
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, Trustee.
Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits for diagnostic procedures under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse and stepdaughter were referred to Hahnemann Medical Center for a muscle biopsy to determine their susceptibility to malignant hyperthermia. Malignant hyperthermia is a disorder characterized by a rapid, extreme and often fatal rise in body temperature following the administration of certain anesthetic agents. Malignant hyperthermia is an inherited disorder. The Employee’s spouse’s mother died from malignant hyperthermia, and the Employee’s spouse’s sister had tested positive for susceptibility to the disorder.
On December 21, 1987, the Employee’s spouse underwent a diagnostic muscle biopsy to evaluate her susceptibility to malignant hyperthermia. On December 22, 1987, the Employee’s stepdaughter underwent the same procedure. The Employee’s spouse tested positive and was advised to follow special precautions should she require anesthesia in the future. The Employee’s stepdaughter tested negative for susceptibility to malignant hyperthermia.
The Employee’s spouse has health insurance through her employer, which covered some of the charges incurred by the Employee’s spouse. The Employee’s insurance carrier, as the secondary insurance carrier for the Employee’s spouse, denied payment for the remaining charges. The Employer covered some of the charges incurred by the Employee’s stepdaughter; one of those payments was later retracted, and the remaining charges were denied.
Dispute
Is the Employer required to provide benefits for the diagnostic testing for susceptibility to malignant hyperthermia performed on the Employee’s spouse and stepdaughter?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the diagnostic testing for susceptibility to malignant hyperthermia because such procedures are covered under the Employer Benefit Plan.
Position of the Employer: Neither the Employee’s spouse nor stepdaughter was scheduled for surgery requiring anesthesia; therefore, they were not at risk for developing malignant hyperthermia at the time the tests were performed. The Employer is not required to provide benefits for the diagnostic testing for susceptibility to malignant hyperthermia because it was not medically necessary for the diagnosis or treatment of a definite condition, illness or injury.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan provides:
Covered services 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)(j) and (o) 2. of the Employer Benefit Plan provide:
(3) Physicians’ Services and Other Primary Care
(j) Laboratory Tests and X-rays
Benefits will be provided for laboratory tests and x-rays performed in a licensed laboratory when ordered by a physician for diagnosis or treatment of a definite condition, illness or injury.
Such benefits will not cover laboratory tests and x-rays ordered in connection with a routine physical examination, unless the examination is considered medically necessary by a physician.
(o) Primary Medical 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)(j) of the Employer Benefit Plan provides that “[b]enefits will be provided for laboratory tests … performed … for diagnosis or treatment of a definite condition, illness or injury.” Malignant hyperthermia is a definite condition, and the laboratory work associated with the diagnosis of the condition is therefore covered.
Article III. A. (3)(o) 2. of the Employer Benefit Plan provides that “[b]enefits 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.”
A Funds’ medical consultant has reviewed the documentation provided in this case and advised that because malignant hyperthermia is an inherited disorder, it is medically necessary to diagnose family members who may be susceptible to this condition so that they may safely undergo emergency and elective surgery. The consultant stated that a muscle biopsy is the accepted method of diagnosing this condition, and a patient must be hospitalized in an inpatient setting for this procedure. The consultant is of the opinion that the muscle biopsies performed on the Employee’s spouse and stepdaughter were medically necessary to prevent potentially fatal complications in the event that emergency surgery should be required for either of them. Therefore, the Trustees find that the Employer is required to provide benefits for the medically necessary diagnostic procedures performed on the Employee’s spouse and stepdaughter.
Opinion of the Trustees
The Employer is required to provide benefits for the medically necessary muscle biopsies performed on the Employee’s spouse and stepdaughter.