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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 84-348 – February 18, 1987

Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., 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 health benefits for surgery known as bilateral upper eyelid blepharoplasty, under the terms of the Employer Benefit Plan.

Background Facts

The Employee’s spouse was diagnosed by her family physician as having excessive fat in her upper eyelids, causing protrusion of the upper eyelids and difficulty in closing her eyes. The family physician referred the Employee’s spouse to a plastic surgeon who diagnosed her as having ptosis (drooping) of the upper eyelids which impaired her vision and recommended blepharoplasties for both upper eyelids. The Employee sought prior approval of the recommended surgical procedures from the Employer. The Employer’s medical director referred the Employee’s spouse to a consulting physician, a board-certified family practitioner, for examination and evaluation. According to the consulting physician, the Employee’s spouse stated during the examination that she experienced feelings of heat and heaviness in her upper eyelids; however, she exhibited neither visual symptoms nor problems opening and closing her eyes and offered no complaints concerning her vision. The consulting physician concluded that the proposed eyelid surgery would not be for a functional impairment but would serve cosmetic purposes. The Employer’s medical director concluded that the proposed surgery would be primarily for cosmetic reasons rather than to correct any functional impairment. The Employer determined that the proposed surgery would not be covered and so informed the Employee in a telephone conversation on April 4, 1986, followed up by letter on April 9, 1986. The Employee’s spouse proceeded with the surgery on April 7, 1986.

Dispute

Is the Employer responsible for the provision of health benefits coverage for the Employee’s spouse’s eye surgery?

Positions of the Parties

Position of the Employee: The Employer is responsible for the provision of health benefits coverage for the Employee’s spouse because the purpose of the surgery was to correct a vision impairment.

Position of the Employer: The Employer is not responsible for the Employee’s spouse’s eye surgery because it was cosmetic surgery and is not therefore covered, in accordance with Article III. A. (3) (p) 9.

Pertinent Provisions

Article III. A. (3)(p) of the 1984 Employer Benefit Plan states in part:

(p) Services Not Covered

9. Cosmetic surgery, unless pertaining to surgical scars or to correct results of an accidental injury or birth defects.

Discussion

Under Article III. A. (3)(p) 9 of the Employer Benefit Plan, benefits are provided for cosmetic surgery only if it is for correction of surgical scars, results of an accidental injury, or birth defects. During the prior approval process, the Employer determined, based on the opinions of its medical director and a consulting physician, that the proposed surgery would be cosmetic in nature.

A Funds’ medical consultant has reviewed the available evidence: the attending plastic surgeon’s statement concerning the treatment and surgery performed on the Employee’s spouse, the Employee’s spouse’s family physician’s report and the statements from the Employer’s medical director and consulting physician. The Funds’ medical consultant advised that there was no objective evidence of medical necessity for the procedure and, therefore, that it would be cosmetic in nature.

The Employee requested and was denied prior approval before the surgery was performed. Since the surgery performed on the Employee’s spouse was cosmetic in nature and did not pertain to surgical scars or the correction of results of an accidental injury or birth defects, it is not covered under the Employer Benefit Plan.

Opinion of the Trustees

The Employer is not responsible for providing health benefits coverage for the Employee’s spouse’s eye surgery.