Issued and entered December 19, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On April 24, 2002, Petitioner, XXXXXXXXXX, filed a request for external review with the Commissioner of Financial and Insurance Services under the Patient’s Right to Independent Review Act, MCL 550.1901 et seq. After a review 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 May 10, 2002, the Office of Financial and Insurance Services received from United Wisconsin Life Insurance Company (United Wisconsin) the information it used in making its adverse determination.

II
FACTUAL BACKGROUND

In July 2001, Petitioner sought treatment for pain in her right shoulder. Petitioner’s physician ordered a bone scan and recommended physical therapy. XXXXXXXXXXXXXX XXXXXXXXXXXX contacted United Wisconsin to obtain pre-certification for the prescribed physical therapy. United Wisconsin pre-authorized 12 physical therapy visits and Petitioner proceeded with her therapy.

United Wisconsin provided coverage for the physical therapy. However, a portion of the physical therapy was covered as manipulative therapy, which has a limited benefit of 10 visits per calendar year with a $25.00 maximum benefit per visit.

III
ISSUE

Did United Wisconsin comply with the terms of its certificate of insurance and Michigan law when it applied the limitations of coverage for manipulative therapy to a portion of Petitioner’s prescribed physical therapy?

IV
ANALYSIS

Petitioner’s Argument

Petitioner argues that because XXXXX obtained pre-certification for 12 physical therapy visits from United Wisconsin the charges should be covered at 100% under the physical therapy provision of her certificate of insurance.

Respondent’s Argument

Respondent relies on the precertification provision of the certificate of insurance which states in pertinent part:

PRECERTIFICATION
Precertification allows Us to determine if a proposed treatment or service is Medically Necessary and is covered by the Policy. Our determination is based on the information available to Us at the time of Your request.

Although we may precertify a treatment or services, it does not guarantee that the benefits will be paid. Actual benefits payment may differ based on the information submitted to Us with the claim for benefits, subject to the terms, conditions and provisions of the Policy in effect as of the date when the treatment or service was rendered.

United Wisconsin notes that the services in question were reported by XXXXXXXXXXX with the Current Procedural Terminology (CPT) code number “97124”. CPT Code 97124 is identified as “massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)”. Respondent argues that this procedure is considered manipulative therapy.

The schedule of benefits included in Petitioner’s certificate of group insurance states, in pertinent part:

MEDICAL INSURANCE
Benefit Maximums Per Covered Person:
Lifetime Maximum Per Covered Person. . . . . . . .$5,000,000
All Covered Expenses apply to above Lifetime Maximum. Certain Covered Expenses are payable subject to the following Benefit Maximums. All of these Maximums apply toward the above Lifetime Maximum
* * *
Manipulative Therapy: 10 visits per calendar year
* * *
Covered Expenses:
Doctor and Professional Fees-May be subject to Benefit Maximums in this schedule:
* * *
Manipulative Therapy 100% and subject to benefit maximum of $25 per visit

United Wisconsin initially denied reimbursement for manipulative therapy beyond 10 visits based on these policy provisions. After Petitioner challenged the denial, United Wisconsin paid for manipulative therapy rendered on four additional dates while continuing to apply the $25.00 daily maximum.

Commissioner’s Review

The payment schedule for manipulative therapy is clearly set forth in the certificate of insurance -- $25.00 per visit for up to 10 visits in a calendar year. It is not disputed that the therapy provided to Petitioner was manipulative therapy. The Petitioner asserts that, because precertification for therapy was obtained, the insurer should pay all costs of that therapy. This position is not supported by the certificate of authority which specifically states that precertification approval does not guarantee that particular benefits will be paid. Respondent was correct to apply the limitations of coverage for manipulative therapy to this claim.

V
ORDER

The final adverse determination of United Wisconsin Life Insurance Company is upheld. United Wisconsin is not liable for the remainder of the charges relating to the manipulative therapy for calendar year 2001.

This is a final decision of an administrative agency. Under MCL 550.1915, and MCL 600.631; MCR 7.101 and MCR 7.104, 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.