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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-293 – October 22, 1991
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 coverage for prescription drugs under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s physician states that he is currently treating the Employee for hypercholesterolemia (high cholesterol) and hypometabolism (low metabolic rate). The physician has prescribed Didrex, Fastin and Vitamin B-12 injections for the Employee, and he states that it is medically necessary for the Employee to take the prescribed medications. The Employer has denied benefits for the charges incurred by the Employee for these prescription drugs and the Vitamin B-12 injections.
Dispute
Is the Employer required to provide benefits for the Employee’s prescription drug charges and Vitamin B-12 injections?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s prescription drug charges and the Vitamin 8-12 injections because the prescribed medications are medically necessary for the treatment of the Employee’s condition, and benefits have been provided for such medications in the past.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s prescription drug charges and Vitamin B-12 injections because Fastin and Didrex
are not indicated as treatment for hypercholesterolemia or hypometabolism and Vitamin B-12 injections are not necessary for the treatment of the Employee’s illnesses.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states:
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.
Covered services that are medically necessary will continue to be provided, and accordingly this paragraph shall not be construed to detract from plan coverage or eligibility as described in this Article III.
Article III. A. (4) (a) of the Employer Benefit Plan states in pertinent part:
(4) Prescription Drugs
(a) Benefits Provided
Benefits are provided for insulin and prescription drugs (only those drugs which by Federal or State law require a prescription) dispensed by a licensed pharmacist and prescribed by a (I) physician for treatment or control of an illness or a non-occupational accident or (ii) licensed dentist for treatment following the performance of those oral surgical services set forth In (3)(e)….
Discussion
The Introduction to Article III of the Employer Benefit Plan provides that covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury. 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 the Employer Benefit Plan. Under Article III. A. (4) (a) of the Employer Benefit Plan, benefits are provided for insulin and prescription drugs (only those drugs which by Federal or State law require a prescription) dispensed by a licensed pharmacist and prescribed by a physician for treatment or control of an illness or a non-occupational accident.
A physician has diagnosed the Employee with hypercholesterolemia and hypometabolism. A Funds’ medical consultant has reviewed the information submitted in this case and advised that the prescription drugs Fastin and Didrex, which are used to treat obesity, are of limited value and have multiple contraindications. The consultant has advised that Fastin and Didrex are indicated for short-term use (a few weeks) as adjuncts to a weight reduction diet; they are not indicated for the treatment of this patient’s medical conditions which are stated to be hypercholesterolemia and hypometabolism. The medical consultant has also advised that Vitamin B-12 injections are indicated for the treatment of specific medical conditions; however, hypercholesterolemia and hypometabolism are not among those conditions. The medical consultant advises that the use of Fastin, Didrex and Vitamin B-12 injections is not medically reasonable and necessary for the treatment of the Employee’s medical conditions. Therefore, the Trustees conclude that the Employer is not required to provide benefits for these medications. In addition, the fact that the Employer previously provided benefits for such medications does not make the services in question covered benefits under the terms of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for the Employee’s prescription drug charges and Vitamin B-12 injections that were determined not medically necessary.