Issued and entered October 28, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On September 11, 2002, Petitioner XXXXXXXXXXXXX, filed a request for external review with the Commissioner of the Office of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act, MCL 550.1901 to MCL 550.1929. After an assessment of the material submitted, the Commissioner accepted the request.

The issue involved is contractual in nature. There is no medical issue; therefore, review by an Independent Review Organization is not required. The Commissioner reviews contractual issues under MCL 550.1911(7). On October 17, 2002, the Office of Financial and Insurance Services (OFIS) received from Physicians Health Plan of Mid-Michigan (PHPMM) the information it used to make its final adverse determination in Petitioner’s case.

II
FACTUAL BACKGROUND

Petitioner’s husband was a PHPMM member, but his coverage terminated on March 31, 2002. Petitioner is seeking reimbursement for the cost of follow-up care after her husband’s non-covered Lasik eye surgery.

Petitioner telephoned PHPMM on March 19, 2002, to clarify what coverage was available to her husband for follow-up visits after non-covered Lasik eye surgery. PHPMM phone records show Petitioner was told her husband’s follow-up visits to the eye doctor after non-covered eye surgery would be covered. Petitioner’s husband underwent Lasik eye surgery in Canada on March 21, 2002, and saw an ophthalmologist in Michigan for follow-up care on March 28, 2002. The Michigan ophthalmologist charged Petitioner’s husband $400 for that visit and for two more visits he would receive at later dates. Petitioner’s husband paid that amount with his credit card, believing PHPMM would reimburse him. He received the remaining follow-up care after his coverage terminated.

The ophthalmologist billed PHPMM for his services with billing code 65760—Keratomileusis. PHPMM denied coverage claiming Keratomileusis was not a covered benefit under the Certificate of Coverage. PHPMM received a letter from Petitioner on July 26, 2002, initiating the internal grievance process. PHPMM issued its final adverse decision in this matter on August 18, 2002. PHPMM upheld its denial because the Certificate of Coverage specifically excludes coverage for refractive eye surgery, and because Petitioner’s husband went for two of his follow-up visits after his individual coverage had terminated.

III
ISSUE

Whether PHPMM properly denied Petitioner coverage for services from his Michigan ophthalmologist billed as procedure code 65760 (Keratomileusis)?

IV
ANALYSIS

PETITIONER’S ARGUMENT

Petitioner argues PHPMM should reimburse her husband for the cost of his follow-up visits after Lasik eye surgery because PHPMM told her the visits would be covered. She contends that if her husband had known PHPMM would not cover the visits to his Michigan ophthalmologist, he would have had the follow-up visits in Canada where he underwent the surgery. The Canadian doctors who performed the surgery would not have charged the Petitioner’s husband because follow-up care was included in the price of the surgery. Petitioner asserts her husband would not have incurred the $400 in charges from the Michigan ophthalmologist, but for PHPMM’s statement that it would cover those costs. As a result, PHPMM’s assurances of coverage should make them responsible for the cost of the visits.

PHPMM’S ARGUMENT

In its letter to OFIS, dated October 17, 2002, PHPMM argues:

THE SUBJECT MATTER IN DISPUTE RELATES TO SERVICES PERFORMED WHICH ARE EXCLUDED FROM COVERAGE UNDER THE PETITIONER’S BENEFIT CONTRACT.

[Petitioner] seeks coverage of follow-up visits after Lasik eye surgery. PHPMM has an express exclusion related to the surgery and associated expenses for Lasik and other eye surgeries. This exclusion is clearly described in Section 11.1F of the HMO benefit contract…which provide[s] that:

“Health Services and associated expenses for…radial keratotomy and other refractive eye surgery” are excluded…

The language is clear and unambiguous. The dispute appears primarily centered around the services actually being performed. PHPMM does provide coverage for:

“Eye examinations provided by a Network provider in the provider’s office.” (Section 10.2)

However, the service performed by XX. XXXXXXX is not an eye examination. An eye examination which would be a covered benefit would include CPT codes 92012 and 92014 which are:

92012. Opthalmological service; medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient.
92014. Comprehensive, established patient one or more visits.

Descriptions from American Medical Association, Current Procedural Terminology, 2002.)

The services billed were for procedure code 65760—Keratomileusis. Keratomileusis is defined as:

Plastic surgery of the cornea in which a portion is removed and frozen and its curvature reshaped; then it is reattached to the cornea. (Definition from Taber’s Cyclopedia Medical Dictionary, Edition 19, 2001)

It is clear that the procedure code billed is for a surgery, not an eye examination. As it is a surgical procedure related to Lasik surgery, it is excluded as an eye surgery and associated expense.

If the treating physician submits a claim supporting an eye examination, that procedure would be paid. If the physician is, in fact, providing a surgical procedure, and has billed it properly, than the service is not covered.

PHPMM HAS NOT PROVIDED ERRONEOUS BENEFIT INQUIRY QUOTATIONS.

[Petitioner] claims that PHPMM gave wrong information regarding coverage for follow-up visits. This statement is correct but the claims submitted by the physician are not follow-up visits, they are surgical procedures.

PHPMM believes that this dispute has arisen because the physician has either 1) billed incorrectly, or 2) provided a service that was not what he advised the [Petitioner]. In either situation the dispute lies with the physician, not PHPMM. The physician should either submit a corrected claim for an eye examination if that was performed, or should be writing off the charges for having made misstatements to the [Petitioner].

CONCLUSION

PHPMM believes that this dispute is physician rooted. PHPMM expressly excludes, in its prior-approved benefit contract, services and associated expenses for corrective eye surgery. The procedure billed, which may or may not be reflective of services actually performed, is surgical and thus, was properly denied. Grievant should be seeking resolution of this matter through the physician, not PHPMM.

COMMISSIONER’S REVIEW

The Commissioner carefully reviewed the arguments and documents presented by the parties. PHPMM’s denial of coverage for Petitioner’s husband in this case was for Keratomileusis (procedure code 65760). This is the service for which his Michigan ophthalmologist filed a claim. PHPMM did not deny Petitioner’s husband coverage for follow-up ophthalmologist “visits” after Lasik eye surgery. The focus of this analysis is whether PHPMM advised Petitioner that it would cover Keratomileusis as part of her husband’s follow-up care after non-covered Lasik eye surgery. Keratomileusis is clearly not a covered benefit under the PHPMM Certificate of Coverage (Section 11.1F); however, if PHPMM informed Petitioner that it would cover Keratomileusis in this case, Petitioner’s husband may be entitled to that coverage.

Normally, PHPMM does not cover any services related to Lasik eye surgery, but a PHPMM customer service representative told Petitioner that it would cover follow-up ophthalmologist visits for her husband. PHPMM concedes this point and asserts it is willing to cover follow-up visits based on that quote. However, PHPMM argues the services Petitioner’s husband received from his Michigan ophthalmologist were not follow-up “visits.” The Michigan ophthalmologist billed his services as Keratomileusis—a surgical procedure—so PHPMM found Petitioner’s husband received follow-up eye surgery instead of follow-up ophthalmologist visits. PHPMM notes Keratomileusis is a non-covered refractive eye surgery, and it never told Petitioner that it would cover any eye surgery for her husband. The Commissioner agrees with this portion of PHPMM’s argument in this case. Petitioner and her husband were aware that refractive eye surgery was not a covered benefit under the PHPMM Certificate of Coverage, so it would be unreasonable to expect PHPMM to cover ineligible surgeries when all it agreed to cover was follow-up visits. The Commissioner finds PHPMM’s equation of a follow-up visit to a routine examination is reasonable. Any assumption that coverage of follow-up visits would encompass coverage of surgical procedures is not warranted, especially considering the clear exclusionary language of Section 11.1F of the PHPMM Certificate of Coverage. So, PHPMM did not obligate itself to cover Keratomileusis for Petitioner’s husband. It only obligated itself to cover routine follow-up examinations after his Lasik procedure. Therefore, PHPMM’s final adverse determination in this matter, denying Petitioner’s husband coverage for Keratomileusis, is valid.

Furthermore, PHPMM is not required to cover Petitioner’s husband for any services he received after his individual coverage terminated. Section 11.1AD of his Certificate of Coverage clearly and unambiguously excludes coverage for:

Health Services otherwise Covered under the Policy, but rendered after the date individual Coverage under the Policy terminates, including Health Services for medical conditions arising prior to the date individual Coverage under the Policy Terminates.

PHPMM made no representation to Petitioner or her husband that its extension of coverage to follow-up ophthalmologist visits would continue beyond a termination of individual coverage. Petitioner’s husband went for follow-up ophthalmologist services twice after his PHPMM coverage had terminated, so he is not eligible for PHPMM coverage of those services.

V
ORDER

Therefore, it is now ORDERED that PHPMM’s August 18, 2002, final adverse determination in this case is upheld. PHPMM is not required to cover Petitioner’s husband for Keratomileusis rendered by his Michigan ophthalmologist.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.