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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: 07-0028 - 2009年12月10日
受托人: 迈克尔W. 丹尼尔·L·巴克纳. Fassio和Michael H. 荷兰.
The Trustees have reviewed the facts 和 circumstances of this dispute concerning the provision of benefits under the terms of the 雇主 Benefit Plan.
背景事实
The Complainant’s spouse was injured in a car accident in January 2006 和 has been receiving treatment for neck, 从那时起，背部和肩部疼痛. Significant pain has persisted through the use of anti-inflammatory medications, 类固醇, 肌肉松弛剂和麻醉剂. The patient has been seen by neurologists, neurosurgeons 和 pain management specialists. 物理疗法也被尝试过. A TENS (transcutaneous electrical nerve stimulator) unit was prescribed in May 2007. The Respondent has denied benefits for the TENS unit as not medically necessary because medical literature does not support its clinical efficacy.
争端
Is the Respondent required to provide benefits for the TENS unit prescribed for the Complainant’s spouse in May 2007?
双方立场
Position of the 原告: TENS units have been in st和ard use for pain management for decades 和 have been approved by the Food 和 Drug Administration. It is not an experimental device 和 was prescribed only after other treatments failed. 被申请人应当为单位提供福利.
Position of the 被申请人: Medical literature indicates that TENS units are no more effective than placebos in managing pain, 除了运动的好处之外，什么也没有增加. Medical literature does not support the clinical efficacy of TENS for the treatment of this patient’s clinical condition. Therefore, the TENS unit is not medically necessary 和 is not a covered benefit.
相关的规定
The Introduction to 第三条 of the 雇主 Benefit Plan, in pertinent part, states:
第三条福利待遇
Covered services shall be limited to those services which are reasonable 和 necessary for the diagnosis or treatment of an illness or injury 和 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 it 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. The benefits described in this Article are subject to any precertification, 处方药处方(PDP)要求, 和 other utilization review requirements implemented pursuant to Article IV. Covered services that are medically necessary will continue to be provided, 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 第三条.
第三条. A. 雇主福利计划第(6)(d)条规定:
(d) 医疗设备
提供租金或租金福利, 在适当的地方, purchase of medical equipment suitable for home use when determined to be medically necessary by a physician.
第三条. A. (11) (a) 24. 的“雇主福利计划”声明:
(11)一般除外条款
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits
也不提供以下服务:
24. Charges for treatment with new technological medical devices, therapy
哪些是实验性的.
讨论
The Complainant’s spouse suffers from chronic pain that has been resistant to conservative therapy. The spouse sought treatment by numerous physicians who tried multiple modalities to reduce her level of pain. 保守疼痛治疗失败, 和, 一年之后, 主治医生建议使用TENS装置. 经过TENS治疗后, 病人说疼痛减轻了, 和 the amount of medication needed to control the pain has been reduced.
被告否认了对TENS单位的指控, citing research that found TENS units to be no more effective than treatment with a placebo in addition to adding no apparent benefit to exercise alone. Respondent considers the TENS unit to be experimental 和 not medically necessary.
Funds’ Medical Director has reviewed the facts of this case 和 states that, 在新出现的治疗方法中, 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 和 therapies by the medical community. 医疗保险 covers TENS units for patients with chronic 和 intractable pain. 医疗保险 requires that the pain has been present for at least three months 和 that other treatments have been tried. Funds’ Medical Director has determined that the medical records submitted document that 医疗保险 requirements have been met in this case 和 that the TENS unit is medically necessary.
受托人的意见
Consistent with the provisions of the 雇主 Benefit Plan, the Respondent is required to
provide benefits for the TENS unit purchased for the Complainant’s spouse.