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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 84-712 – January 16, 1990
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 chelation therapy for a Pensioner under the terms of the Employer Benefit Plan.
Background Facts
The Pensioner’s physician administered eleven chelation therapy treatments to the Pensioner between July 29, 1987 and August 25, 1987. Chelation therapy removes unwanted metal ions from the body. The Pensioner’s physician states that the chelation therapy was medically necessary to treat the Pensioner’s arteriosclerosis, obstructive atherosclerosis and hemochromatosis (a disorder of iron metabolism) with excessive body burden of iron. The Pensioner’s physician also states that the Pensioner’s arterial problems have improved with the chelation treatments and that his body burden of iron has decreased.
The Employer has denied benefits for the chelation therapy administered to the Pensioner between July 29, 1987 and August 26, 1987.
Dispute
Is the Employer required to provide benefits for the chelation therapy administered to the Pensioner between July 29, 1987 and August 26, 1987?
Positions of the Parties
Position of the Pensioner: The Pensioner asks whether the chelation therapy he received between July 29, 1987 and August 26, 1987 is a covered service under the Employer Benefit Plan.
Position of the Employer: The Employer is not required to provide benefits for the Pensioner’s chelation therapy because its medical necessity has not been established.
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.
Discussion
The Introduction to Article III of the Employer Benefit Plan states that covered services are limited to those services that are reasonable and necessary for the diagnosis or treatment of an illness or injury.
In this case, the patient received chelation therapy on eleven occasions between July 29, 1987 and August 26, 1987. A Funds’ medical consultant has reviewed the information submitted in this file. The consultant advises that chelation therapy is used primarily for acute, severe heavy metal intoxication with treatment limited to a short period of time (generally a few days). Chelation therapy is used by some practitioners to treat atherosclerosis and arteriosclerosis; however, the consultant advises that chelation therapy is not currently an accepted treatment in this country for arteriosclerosis, atherosclerosis or coronary artery disease. The consultant further states that hemochromatosis with excessive body burden of iron is not considered an acute heavy metal intoxication that warrants chelation therapy. The consultant is therefore of the opinion that the chelation therapy provided in this case is not medically necessary for the treatment of the
patient’s medical condition. Because the medical necessity of the chelation therapy administered to the Pensioner has not been established, the Employer is not responsible for such therapy in this instance.
Opinion of Trustees
The Employer is not required to provide benefits for the chelation therapy administered to the Pensioner between July 29, 1987 and August 26, 1987.