occurrence of tooth brushing, dental caries, HbAlc level and diabetes adherence. patients who visited the diabetes clinics during the sampling days. …
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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-455 - October 29, 1991
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 benefits for
an insulin injection device under the terms of the Employer Benefit Plan
Background Facts
The Employees 19-year-old son has juvenile onset diabetes mellitus, a
chronic form of diabetes involving insulin deficiency, and he receives
insulin injections twice daily His physician has stated that he has good
diabetic control, but he frequently has a small amount of bleeding at the
injection site and has numerous bruises The physician has
prescribed a
Medi-Jector needle-free insulin injection device, stating that he thinks
its use will decrease the Employees sons hemorrhagic response to insulin
Injections and will relieve a disturbing side effect from injections with a
needle The Employer has denied benefits for the purchase of -the insulin
Injection device
Dispute
Is the Employer required to provide benefits for the insulin injection
device?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for
the needle-free insulin injection device because injections with a needle
have resulted in bleeding and other problems
Position of the Employer: The Employer is not required to provide benefits
for the insulin injection device because it is an item of convenience and
is not medically necessary for the treatment of the Employees sons
diabetes; regular insulin syringes would serve the same purpose at a more
reasonable cost
Pertinent Provisions
Article III A 6d of the Employer Benefit Plan provides:
6 Home Health Services Equipment
d Medical Equipment
Benefits are provided for rental or, where appropriate,
purchase of medical equipment suitable for home use when
determined to be medically necessary by a physician
QA 81-38 states in pertinent part:
Subject: Medical Equipment and Supplies
References: Amended 1950 1974 Benefit Plans Trusts,
Article III Sections A 6d and e, and A 7 a and
d
Question:
What medical equipment and supplies are covered under the Plan?
Answer:
A Under the Home Health Services and Equipment provision, benefits are
provided for the rental and, where appropriate as determined by the
Plan Administrator, purchase of medical equipment and supplies
including items essential to the effective use of the equipment
suitable for home use when determined to be medically necessary by a
physician These supplies and equipment include, but are not limited
to, the following:
2 Medical supplies necessary to maintain homebound or bedridden
Beneficiaries Examples of covered supplies are enema supplies,
disposable sheets and pads also called Chux or blue pads,
supplies for home management of open or draining wounds,
heating
pads for therapeutic use only] and insulin needles and
syringes
Discussion
Article III A 6d of the Employer Benefit Plan provides benefits for
medical equipment suitable for home use when determined to be medically
necessary by a physician QA 81-38, states that, under the Home Health
Services and Equipment provision, benefits are provided for certain types
of medical equipment and supplies, including insulin needles and syringes
A Funds medical consultant has reviewed this file, including a letter from
the Employees sons physician He notes that the prescribed Medi-Jector
is an alternative means of delivering the patients insulin by using a jet
of air instead of a needle The consultant finds no medical documentation
to indicate that the patients bleeding cannot be controlled by better
technique using traditional means of insulin injection The consultant
further states that there is no medical evidence that the patient has a
bleeding disorder and no medical evidence that the Medi-Jector produces
less bleeding or a smaller contusion The consultant is of the opinion
that the use of a Medi-Jector in this case would not provide any
medical
advantages over a conventional hypodermic insulin syringe and is not
medically necessary
Since the insulin injection device prescribed in this case is not medically
necessary, the Employer is not required to provide benefits for it under
the terms of the Employer Benefit Plan
Opinion of the Trustees
The Employer is not required to provide benefits for the insulin injection
device
Source:mnhealthplans.org
