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OPINION OF TRUSTEES
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In Re

Complainant: Pensioner
Respondent: Employer
ROD Case No: 07-0057 – July 26, 2011

Trustees: Micheal W. Buckner, Daniel L. Fassio, Morris D. Feibusch, and Michael
H. Holland

受托人审查了有关根据雇主福利计划条款提供福利的争议的事实和情况.

Background Facts

申诉人的配偶因慢性鼻窦问题接受了治疗，并被转介到耳科, 鼻喉科专家. 专家诊断为鼻窦炎，并建议手术治疗称为鼻中隔成形术和双侧下鼻甲肥大来解决慢性疾病. 该专家向答辩人提交了一份请求，要求预先授权所推荐的外科手术, 但答辩人认为这些程序在医学上没有必要，并拒绝给予预先授权.

Dispute

所要求的外科手术是否在2007年雇主福利计划的意义上是医学上必需的?

Positions of the Parties

投诉人的立场:该程序是由一名律师建议的, 鼻喉科专家, therefore, medically necessary.

Position of the Respondent: The requested surgical procedures are not medically necessary; therefore, 被投诉人不需要为该程序提供保险.

Pertinent Provisions

《官方网站》第三条导言中有相关部分说明:

ARTICLE III BENEFITS

…承保的服务应限于诊断或治疗疾病或伤害是合理和必要的，并以适当的护理水平提供的服务, 或计划另有规定. 医生规定的程序或护理水平并不意味着它在医学上是合理的或必要的，也不意味着它在本计划范围内. 在确定合理性和必要性的问题上, 将适当考虑提供服务的社区医生的习惯做法. 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 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.

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Discussion

《官方网站》第三条的导言指出，只为医疗上必要的服务提供保险. 养恤皇冠搏彩中心网站医务主任审查了本案的事实, 包括医疗记录和申诉人的CT扫描报告
配偶的鼻窦, 并认为拟议的外科手术不符合雇主福利计划第三条的医疗需要要求.

Opinion of the Trustees

符合雇主福利计划的规定, 所要求的外科手术在医学上是不必要的, and, therefore, 被告不需要提供这些信息.