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受托人的意见
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在再保险
原告: 养老金领取者
被申请人: 雇主
ROD案例编号: CA-082 - 2007年7月25日
受托人: 迈克尔W. 巴克纳,. 弗兰克·邓纳姆，迈克尔·H. 荷兰, 艾略特一. 西格尔.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the 雇主 Benefit Plan.
背景事实
Complainant’s spouse sought treatment for pain in the right shoulder following a fall. 开始初步治疗三周后, her physician prescribed a series of occupational therapy treatments using Iontophoresis with Dexamethasone to decrease tenderness and inflammation of the rotator cuff. Iontophoresis is the introduction of ions of soluble salts into tissues of the body by means of an electric current. It is a form of electro-osmosis and its use is often for therapeutic purposes. 它也被称为离子疗法. 对申诉人的配偶进行了8次离子电泳. The 雇主 has refused to pay for the portions of occupational therapy that involved the use of Iontophoresis.
争端
Is the 雇主 required to provide benefits for the occupational therapy using Iontophoresis?
双方立场
Position of the 原告: The services provided to the Complainant’s spouse were prescribed by her physician and were effective in treating her injury. 这些治疗应包括在雇主的健康计划之内.
Position of the 被申请人: The denied services are experimental and investigational in nature and therefore are not covered under the 雇主 Benefit Plan.
相关的规定
雇主福利计划第三条导言中规定:
第三条福利待遇
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, 或计划另有规定. 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 is covered under this Plan. 在确定合理性和必要性的问题上, due consideration will be given to the customary practices of physicians in the community where the service is provided. 不合理和不必要的服务包括, but are not limited to the following: procedures which are of unproven value or of current questionable 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 a timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care. 本条中所述的益处须经任何预认证, 处方药处方(PDP)要求, and other utilization review requirements implemented pursuant to Article IV. 将继续提供医疗上必要的承保服务, 和相应的, 而福利金则受规定的限额限制, this paragraph shall not be construed to detract from plan coverage or eligibility as described in this Article III.
第三条A. 有关部分各国:
第三条
A. 健康的好处
(2)医院门诊福利
(e)物理疗法
Benefits are provided for physiotherapy treatments performed in the outpatient department of a hospital. 这种治疗必须由医生开处方并监督.
(3)医生服务和其他初级保健
(m)专科护理
Benefits will be provided for treatment prescribed or administered by a specialist if the treatment is for illness or injury which falls within the specialist’s area of medical competence.
(7)其他福利
(b)物理治疗
在医院进行物理治疗可获得津贴, 熟练的护理设施, 治疗中心, 或在受益人家中. Such therapy must be prescribed and supervised by a physician and administered by a licensed therapist. 物理治疗必须在诊断的基础上证明是合理的, 医疗建议和达到最大程度的恢复.
(11)一般除外条款
(a)除了《皇冠搏彩中心》中另有规定的具体除外事项之外, 以下情况也不提供福利:
24. Charges for treatment with new technological medical devices, therapy which 本质上是实验性的.
讨论
申诉人配偶因肩部疼痛而接受的初步治疗, 包括使用干扰刺激和电超声, 导致症状在三周内集中. It was at this time that Iontophoresis was initiated and continued for eight occupational therapy visits, 11月9日结束, 2005. The Complainant’s spouse reported a decrease in pain after receiving Iontophoresis, 自11月9日以来一直没有返回接受进一步治疗, 2005.
被告引用第三条A款. 雇主福利计划第(11)(a) 24条, which states that therapies considered experimental in nature are not covered by the Plan. The case was reviewed for the Respondent by a licensed physical therapist who concluded that Iontophoresis has not been shown superior to standard methods of administering medications in the peer reviewed literature. 根据答辩人, 概要计划描述(SPD), 在题为“未付费用”一节下,声明该计划不包括“治疗”, 被认为是实验性或研究性的程序或装置, 由索赔管理员确定.”
The Introduction to Article III states that in determining whether or not a therapy is medically reasonable, due consideration will be given to the customary practices of physicians in the community where the service is provided. Funds’ Medical Director has reviewed the facts of this case and states that in cases of emerging treatments and therapies, the Funds relies on 医疗保险 policy of coverage of these modalities to determine if they are still investigational or are considered accepted treatments and therapies by the medical community. 关于离子电泳, 医疗保险没有全国性的政策, but leaves the coverage up to the local Part A intermediaries or Part B carriers. 当地的医疗保险政策混合了许多
those who do cover the therapy supporting it for the delivery of topical medications such as dexamethasone, 投诉人的配偶收到了什么. 西弗吉尼亚州的医疗保险中介, 申诉人的配偶在哪里接受治疗, covers Iontophoresis provided there is medical documentation of the need for such therapy.
It is the opinion of Funds’ Medical Director that the occupational therapy with Iontophoresis administered to the Complainant’s spouse in New Martinsville, WV, was medically necessary and covered by Article III of the Benefit Fund Administration (雇主 Plan).
受托人的意见
符合雇主福利计划的规定, the Respondent is required to provide benefits for the Iontophoresis treatments administered to the Complainant’s spouse.