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

ORDER

I
PROCEDURAL BACKGROUND

On March 20, 2002, XXXXXXXXX (Petitioner), filed a request for an external review with the Commissioner of Financial and Insurance Services (Commissioner), under the Patient’s Right to Independent Review Act (PRIRA), MCL 550.1901 et seq. After reviewing the material submitted, the Commissioner accepted the request. The Commissioner initially believed the case only involved analysis of contractual issues. However, after review of the documents and arguments provided by the parties, the Commissioner determined this case required analysis by an independent review organization (IRO). The Commissioner assigned the case to Permedion, an IRO. The Commissioner directed IRO to obtain the opinion and recommendation of a medical expert. The IRO completed its review on April 23, 2002 and forwarded it to the Office of Financial and Insurance Services (OFIS). XXXXXXXXXXXXXXXX

II
FACTUAL BACKGROUND

Petitioner had breast augmentation surgery in XXXXXXXX. In XXXXXXX, she returned to her surgeon, complaining of pain and a lump in her right breast. However, no treatment was provided. On XXXXXXXXXX Petitioner again returned to her surgeon complaining of extreme tenderness in her left breast. Again, no treatment was provided.

In XXXXX, Petitioner was still experiencing pain. This time she saw her gynecologist who believed that the silicone bag in her left breast was displaced. Later, during theXXXX of XXXX, Petitioner indicated that she experienced a very forceful impact with the water while she slid down a waterslide at a swimming pool. Petitioner claimed that this impact resulted in a great deal of pain to her left breast. Afterward, Petitioner also noted her left breast hardened. Following this incident, Petitioner consulted with the surgeon who performed her breast surgery and he recommended that she consider replacing her silicone implants with saline implants.

On XXXXXXXXXXX, Petitioner again saw her surgeon regarding continued pain in and capsulation of her left breast. At that time, Petitioner’s surgeon specifically determined that Petitioner’s left breast capsule should be replaced. He further determined that both implants should be redone due to displacement. He also determined that saline implants should replace the silicone implants. Petitioner had surgery performed on her breasts in XXXXXXXXXX. During this surgery it was determined the gel-filled bag in her left breast had indeed ruptured.

On XXXXXXXXX, Petitioner underwent a series of lab tests due to a six-year history of recurrent kidney and bladder infections, constant fatigue, candidiases, hormone imbalance, dyspepsia, bowel dysbiosis, and hypothyroidism.

John Alden denied Petitioner coverage for the removal of her silicone breast implants and the replacement with saline breast implants under its policy provision which excludes “cosmetic treatment or surgery or any complication therefrom.” John Alden also denied coverage for a majority of the Petitioner’s XXXXXX lab tests under its policy provision, which provides that only medically necessary services are covered.

III
ISSUES

1. Whether John Alden properly denied coverage for removal of Petitioner’s silicone breast implants and replacement with saline breast implants.

2. Whether John Alden properly denied coverage of Petitioner’s lab tests performed in XXXXXX.

IV
ANALYSIS

Petitioner’s Position

Petitioner claims she suffered an injury in XXXXXXXX while sliding down a water slide and this injury caused displacement and/or rupture of her silicone breast implants. Petitioner claims that her insurance policy with John Alden covers treatment concerning her breast implants since she sustained this injury while her policy was in force. Petitioner claims John Alden should cover the lab work performed in XXXXXXXX since her doctor ordered the tests as medically necessary in order to assist in diagnosing the cause of the various symptoms she was then experiencing.

Petitioner argues that John Alden should pay the full amount of her surgery and the cost of all her lab work except the hair analysis, which she was advised in advance was not covered.

John Alden Life Insurance Company

On February 19, 2002, John Alden issued a final adverse determination regarding Petitioner’s surgery. On December 11, 2001, John Alden issued a final adverse determination regarding Petitioner’s lab tests.

John Alden claims it denied coverage of the surgery to remove Petitioner’s breast implants and Petitioner’s XXXXXXXX laboratory tests based on a contractual provision of its Certificate of Group Insurance. John Alden also claims that the laboratory tests were done specifically to determine the etiology of Petitioner’s health complaints, which were based on her breast implants.

John Alden indicates that its Certificate of Group Insurance, provides at pages 25 and 26:

Charges Not Covered

Covered Medical Charges do not include any changes:
…

16. For Cosmetic treatment or surgery, or any complication therefrom, except for the following: (a) correction of damage caused by accidental Injury sustained while insured under this plan if such treatment or surgery is also performed while so Insured; or (b) in connection with congenital defects, malformations or abnormalities present at birth.

John Alden claims that they did not deny the treatment as not being medically necessary, but denied the treatment on the basis that it was specifically excluded from coverage under the Certificate of Insurance.

Independent Review Organization (IRO) Recommendation

A physician board certified in Internal Medicine performed the IRO review. The IRO review concluded that both the laboratory tests and the surgery to remove and replace the breast implants were directly related. The IRO review therefore concluded that both the surgery and laboratory tests were not covered under the policy provision that specifically excludes benefits for cosmetic procedures and complications from cosmetic procedures. As a result, the IRO concluded that John Alden was not responsible to pay for Petitioner’s surgery or laboratory work.

Commissioner’s Review

The Commissioner concurs with the IRO recommendation. It is clear from the medical reports that the claims submitted by Petitioner are directly related to a cosmetic procedure and complications resulting from this cosmetic procedure. Petitioner’s coverage with John Alden specifically excludes such claims. Therefore, John Alden is not required to pay for the surgery or lab tests for which Petitioner seeks recovery in this case.

V
ORDER

It is ORDERED that the final adverse determination of John Alden Life Insurance Company is upheld. John Alden is not required to approve coverage for Petitioner’s claims related to the removal of her breast implants or for the laboratory work Petitioner had performed between XXXXX and XXXXXXXX.

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 (60) 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.