Issued and entered December 27, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On June 18, 2002 the 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 to MCL 550.1929. After a review of the material submitted, the Commissioner accepted the request. The issue involved was medical in nature. Accordingly, the Commissioner assigned it to an independent review organization (“IRO”) which provided its report, or external medical review, on June 25, 2002.

II
FACTUAL BACKGROUND

The Petitioner received radial keratotomy surgery in December 1994 because Petitioner was having problems with corrective lenses. During a follow up visit, it was decided an enhancement was required and the procedure was re-performed in April 1995.

During an examination August 9, 1995, it was found that the vision in his right eye had deteriorated and that LASIK surgery would be the next step in correcting the Petitioner’s vision. The surgery was performed on May 9, 2001. Blue Cross and Blue Shield of Michigan (“BCBSM”) denied payment for the LASIK procedure.

III
ISSUE

Did BCBSM properly deny reimbursement for the Petitioner’s LASIK surgery?

IV
ANALYSIS

Petitioner’s Argument

The Petitioner states that he had RK surgery in 1995 because he was having problems with corrective lenses and to facilitate not having to wear corrective lenses. BCBSM covered this service. However, the vision in his right eye was not fully restored to the level of the left eye. This was causing problems with headaches and his vision. He was concerned that the vision in his left eye would deteriorate. Therefore, after a period of time to allow the eye to heal, he has LASIK surgery in 2001.

The Petitioner has been trying for over a year to get BCBSM to pay for his LASIK surgery. Initially, BCBSM failed to pay because the proper procedure code was not used. Later, BCBSM claimed the procedure was done for convenience and was not medically necessary. The Petitioner argues that this is not true because it is not a convenience to see properly and not have headaches. He argues that BCBSM cannot deny the LASIK procedure when it paid for the original RK procedure. He indicates that several other insurance companies reimburse for LASIK and BCBSM should do the same.

BCBSM’s Argument

BCBSM states the Petitioner is enrolled for health coverage through XXXXXXXXXX XXXXXXX. His coverage is governed by the terms of BCBSM’s Professional Services Group Benefit Certificate. The relevant provisions include the following:

Medically Necessary

A service must be medically necessary in order to be covered. Medical necessity is the determination by physicians acting for BCBSM, based on criteria and guidelines developed by physicians for BCBSM who are acting for their respective provider type and/or medical specialty, that:

• The covered service is accepted as necessary and appropriate for the patient’s condition. It is not mainly for the convenience of the member or physician.

BCBSM’s medical consultant reviewed the information provided by the Petitioner and his doctor. The consultant concluded that the LASIK surgery appeared to have been done so that the patient would not have to wear glasses. Therefore, BCBSM judged that the procedure was done for Petitioner’s convenience, not as a matter of medical necessity. For that reason, BCBSM concluded the surgery should not be deemed a covered benefit.

IRO Recommendation

The IRO determined that the amount of near-sightedness the Petitioner had corrected in his right eye was modest and should be considered elective in nature. In addition, the imbalance in the Petitioner’s vision could have been corrected with spectacles or contact lenses.

Commissioner’s Review

BCBSM established that for a service to be a covered benefit under the Certificate it must be medically necessary. The Certificate also states that to be medically necessary a service must be accepted as necessary and appropriate for the patient’s condition. The service is not mainly for the convenience of the member or physician.

It was the medical judgment of the IRO that the LASIK surgery was undertaken to correct a modest amount of myopia which could have been corrected with spectacles. The IRO reviewer is Board certified in ophthalmology and has no conflict of interest in this dispute. The reviewer had the benefit of reviewing the medical records in this matter. There is no reason to conclude that the reviewer’s judgment was erroneous. The Commissioner adopts the IRO’s finding that the procedure in question was elective in nature. The IRO’s external medical review is incorporated as a part of this order. A copy is attached.

IV
ORDER

The final adverse determination of BCBSM is upheld. BCBSM is not required to reimburse Petitioner for the LASIK surgery performed on May 9, 2001.

This is a final decision of an administrative agency. Under MCL 550.1915, 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.