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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 88-466 – December 17, 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 benefits for a blood pressure monitor under the terms of the Employer Benefit Plan.
Background Facts
The Pensioner has been treated for high blood pressure for several years. His physician states that his blood pressure is labile (subject to change), and the Pensioner therefore needs an automatic blood pressure monitor to check his blood pressure regularly at home.
Dispute
Is the Employer required to provide benefits for’ an automatic blood pressure monitor?
Positions of the Parties
Position of the Pensioner: The Employer is required to provide benefits for the automatic blood pressure monitor because the Pensioner’s physician has stated that the monitor is necessary to monitor his blood pressure at home.
Position of the Employer: The Employer is not required to provide benefits for the automatic blood pressure machine because: (1) it can be purchased without a prescription or recommendation from a physician; (2) it is an item of convenience that is not necessary for the treatment of an illness or injury; and (3) anyone could benefit from its use.
Pertinent Provisions
Article III. A. (6)(d) of the Employer Benefit Plan states:
(6) Home Health Services & Equipment
(d) Medical Equipment
Benefits are provided for rental or, where appropriate, purchase of medical equipment suitable for home use when determined to be medically necessary by a physician.
Q&A 81-38 states in pertinent part:
Subject: Medical Equipment and Supplies
References: Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Sections A (6) (d) and (e), and A (7) (a) and (d)
Question:
What medical equipment and supplies are covered under the Plan?
Answer:
A. Under the Home Health Services and Equipment provision, benefits are provided for the rental and, where appropriate as determined by the Plan Administrator, purchase of medical equipment and supplies (including items essential to the effective use of the equipment) suitable for home use when determined to be medically necessary by a physician. These supplies and equipment include, but are not limited to, the following:
1. Durable Medical Equipment (DME) which (a) can withstand use (i.e., could normally be rented), (b) is primarily and customarily used to service a medical purpose, (c) generally is not useful to a person in the absence of an illness or injury, and (d) is appropriate for use in the home. Examples of covered DME items are canes, commodes and other safety bathroom equipment, home dialysis equipment, hospital beds and mattresses, iron lungs, orthopedic frames and traction devices, oxygen tents, patient lifts, respirators, vaporizers, walkers and wheel chairs.
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C. Items of a convenience nature or those that do not require professional judgment, recommendations or instructions to purchase or use are not covered benefits. Examples of such items are: ordinary support (panty) hose, garter belts, disposable paper cups or towels, cotton balls, cotton swabs, bandaids, exercise equipment, and foot pads for bunions or calluses.
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Discussion
Under Article III. A. (6)(d) of the Employer Benefit Plan, benefits are provided for medical equipment suitable for home use when determined by a physician to be medically necessary. The type of medical equipment which is covered is further defined by Q&A 81-38, which states that covered medical equipment Is that which (a) can withstand use; (b) is primarily and customarily used to serve a medical purpose; (c) generally is not useful to a person in the absence of an illness or injury; and (d) is appropriate for use in the home.
The blood pressure monitor meets all four criteria. First, it can withstand repeated use. Second, it is primarily and customarily used to serve a medical purpose, in this case to register and record blood pressure. Third, the monitor is not generally useful to a person in the absence of a blood pressure problem. Fourth, the monitor can be safely operated without the assistance of professional personnel and is therefore suitable for home use.
Although an item of DME may meet the criteria outlined in Q&A 81-38, it is covered under Article III. A. (6)(d) of the Employer Benefit Plan only if it is medically necessary for the treatment of an illness or injury. A Funds’ medical consultant has reviewed this file. The consultant notes that the prescription from the Pensioner’s physician provides no documentation of any unique needs of the patient. The consultant is of the opinion that the fact that the patient is under treatment for high blood pressure does not establish the medical necessity for such equipment, and therefore the purchase of this equipment is not medically necessary. Accordingly, the Employer is not responsible for payment of benefits for the prescribed automatic blood pressure machine.
Opinion of the Trustees
The Employer is not required to provide benefits for the automatic blood pressure machine.