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受托人的意见
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在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 88-364 - 1991年3月26日

Board of Trustees: Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. 皮尔斯,小., Trustee; Thomas H. Saggau,受托人.

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, 受托人审查了有关根据雇主福利计划条款提供骨髓移植健康福利的争议的事实和情况.

背景事实

1988年1月, the 员工 underwent surgery to remove a tumor (cranial plasmacytoma) involving the skull and right temporal lobe. The surgery was followed by radiation therapy that was well tolerated. 雇员的医生说，直到1990年5月他因间歇性背部疼痛就诊时才出现症状或复发. 磁共振成像(MRI)扫描显示T-11椎体细胞破坏，左侧股骨区可能有小病变. The 员工 underwent a 3-week course of radiation therapy from June 4 to June 25, 1990.

7月25日, 1990, 该员工的医生将他转到梅奥诊所进行评估，以确定当时是否需要化疗. 1990年8月，梅奥诊所的血液学家对该员工进行了评估，发现其颅骨和左股骨的病变范围比先前注意到的更广泛. 出院诊断为活动性多发性骨髓瘤，血液科医生建议开始化疗，使用Alkeran和强的松或类似的化疗方案作为当时的最佳治疗方法. 血液学家还建议雇员和他的医生，将他的骨髓收集起来保存起来以备将来使用是值得的, given the likelihood of eventual progression of the disease.

该员工的医生建议该员工去大学医疗中心，在化疗开始前采集骨髓. The 员工 contends that on August 30, 1990 a hospital representative was told by the 雇主’s insurance carrier that the harvesting procedure, 以及使用来自供体(同种异体移植)或员工(自体移植)的骨髓进行骨髓移植。, 会全额报销吗. 然而, when the insurance carrier was contacted on September 25, 1990 to pre-certify the 员工’s admission for the bone marrow harvest, 医院代表被告知，该雇员的诊断不包括骨髓移植和相关程序.

The 员工 elected to proceed with the bone marrow harvest. The marrow that was harvested on September 26, 1990 showed myeloma involvement and was considered unusable in an autologous transplant. According to the 员工’s physicians, 多发性骨髓瘤不能用目前的标准化疗治愈，他们现在推荐异体骨髓移植作为目前最好的治疗方法. Because the 员工 has no family members that would be suitable donors of bone marrow, the medical center has requested prior approval for the transplant and related costs before a donor search is initiated.

The 雇主 has denied benefits for the bone marrow harvest performed on September 26, 1990 and has denied prior approval for the proposed allogeneic bone marrow transplant and related charges, stating that such treatment is experimental and investigational in nature and, 像这样, is not covered under the 雇主 Benefit Plan.

争端

Is the 雇主 required to provide benefits for the 员工’s proposed bone marrow transplant and related services?

双方立场

雇员的职位:雇主必须为雇员拟议的骨髓移植和相关程序提供福利，因为这种治疗不是实验性的，而且雇主的保险公司告诉医院代表，这种治疗将包括在内.

雇主的立场:由于该骨髓移植治疗是对雇员多发性骨髓瘤诊断的实验性治疗，雇主不需要为其提供福利. 除了, 雇主声明，其保险公司从未在任何时候通知雇员或医院，有关治疗将包括在内.

相关的规定

第三条. A. (3)(f) of the 雇主 Benefit Plan provides:

(3) Physicians’ Services and Other Primary Care

(f) Surgical Services Limitations

Benefits are not provided for certain surgical services without prior approval of the Plan Administrator. Such surgical procedures include, but are not limited to, the following:
Plastic surgery, including mammoplasty
减少乳房成形术
Intestinal bypass for obesity
胃旁路术治疗肥胖
小脑植入物
背侧刺激器植入
Prosthesis for cleft palate if not covered by crippled children services
器官移植

第三条. A.(11)(a) 24. of the 雇主 Benefit Plan provides:

(11) 一般的除外

(a) 除了 to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:

24. Charges for treatment with new technological medical devices and therapy which are experimental in nature.

讨论

第三条. A. 雇主福利计划的第(3)(f)条规定，未经计划管理者事先批准，不得为器官移植提供福利. 由于雇主的保险公司于8月30日声明，雇员主张雇主应为其拟进行的骨髓移植及相关手术提供福利, 1990年, such services would be covered. 不过, the record clearly indicates that the 雇主 and the provider were notified before services were rendered on September 26, 1990年,, based on the diagnosis given, the patient’s history and the intended procedures, such services were considered investigational and would not be covered.

第三条. A. (11) (a) 24. 该计划不包括使用新技术医疗设备和实验性疗法进行治疗的福利. The 雇主 in this case was advised by its insurance carrier that, on the basis of an oncologist’s review of the medical literature, a bone marrow transplant for treatment of multiple myeloma is considered investigational or experimental. 支持其立场, 雇主还参考了雇员医生的信，信中指出，所推荐的治疗方法“仍被认为是研究性的，因为它尚未被证明是一致有效的”，并且由于这种疾病的罕见性，骨髓移植尚未对大量多发性骨髓瘤患者进行.

医疗保健融资管理局没有将骨髓瘤列为医疗保险计划承保的同种异体或自体骨髓移植的条件之一. 除了, 与三家主要保险公司的接触表明，其中一家保险公司认为骨髓移植诊断多发性骨髓瘤是实验性的, 而另外两家承运商则根据医疗顾问对每个个案的审查，确定这种治疗的承保范围.

A Funds’ medical consultant, who is a practicing oncologist, 回顾了这个病例，并建议到目前为止所做的研究表明骨髓移植在治疗骨髓瘤方面只有很小的成功. 顾问建议多发性骨髓瘤的骨髓移植被认为是实验性的，因为其安全性和有效性尚未确定. The consultant has further advised that there are more conservative therapies available to treat this patient’s condition.

由于在本病例中提出的用于治疗多发性骨髓瘤的骨髓移植在本质上被认为是实验性的, the 雇主 is not required to provide benefits for such transplantation and related services.

受托人的意见

在这种情况下，雇主不需要为雇员拟议的骨髓移植和相关服务提供福利.