Issued and entered March 27, 2003 by Frances K. Wallace, Chief Deputy Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On November 11, 2002, XXXXXXXXXX, on behalf of her husband XXXXXXXXXXXX (“Petitioner”), filed a request for external review with the Commissioner of the Office of Financial and Insurance Services under the Patient’s Right to Independent Review Act (“PRIRA”), MCL 550.1901 et seq. After an assessment of the material submitted, the Commissioner accepted the request.

The review requires the resolution of a medical question. For that reason, the file was forwarded to an independent review organization (“IRO”), as provided in section 11(6) of the PRIRA, MCL 550.1911(6). The IRO submitted its report on December 13, 2002.

II
FACTUAL BACKGROUND

Petitioner is a member of Blue Cross Blue Shield of Michigan (“BCBSM”) through his wife’s BCBSM contract. The terms of coverage are contained in BCBSM’s “Community Blue Group Benefit Certificate”. Petitioner seeks coverage for outpatient whirlpool therapy he underwent between XXXXXXX and XXXXXXXXXXX. Petitioner suffered from a non-healing diabetic ulcer on his left big toe. Following several months of unsuccessful treatment for this condition, his doctors prescribed whirlpool therapy. Petitioner’s toe healed after he received the whirlpool therapy, and he has not had any more problems with diabetic ulcers. BCBSM denied Petitioner coverage for his treatment, stating that his condition did not satisfy its requirements for coverage of whirlpool therapy. Petitioner exhausted BCBSM’s internal grievance procedures, and BCBSM issued a final adverse determination in his case on November 1, 2002.

III
ISSUE

Did BCBSM properly deny Petitioner coverage for whirlpool therapy he underwent to treat a non-healing diabetic ulcer?

IV
ANALYSIS

Petitioner’s Argument

Petitioner argues BCBSM should cover his whirlpool therapy because it was medically necessary. He points out that he received other treatments for his diabetic ulcer from XXXXXXXXXXX through XXXXXXXXX, and his toe did not heal. It was only after this 10-month period that his doctors prescribed whirlpool therapy. Petitioner emphasizes that the whirlpool therapy was not just successful, but that it was in fact the only effective treatment for his condition. Petitioner therefore argues that the Commissioner should reverse BCBSM’s final adverse determination in his case and grant him the coverage he seeks.

Respondent’s Argument

In its November 1, 2002, final adverse determination letter to Petitioner, BCBSM stated:

…At the time of [Petitioner’s] treatment, benefits for whirlpool therapy was limited to patients with burns. Therefore, we are unable to assume liability for the charges incurred.

All of our coverage is subject to certain limitations. With regard to physical therapy, benefits are limited to services rendered in the outpatient department of a hospital, in an approved freestanding facility, or by a certified independent physical therapist. Additionally, the therapy must be designed to improve or restore that patient’s functional level after a loss in musculoskeletal functioning following an illness, injury or surgery that impairs or restricts the patient’s body movement.

With respect to whirlpool therapy, payment is limited to services wherein the patient is being treated for musculoskeletal conditions such as fractures, strains, sprains, and third-degree burns. Wound debridement is not considered intense musculoskeletal rehabilitation and therefore, does not satisfy our criteria for physical therapy.

IRO Recommendation

The IRO physician who reviewed this case is a Board-certified physical medicine and rehabilitation independent medical examiner. The reviewer stated that whirlpool therapy is standard care for the treatment of ulcerations in a vascular-compromised lower extremity. The whirlpool therapy was medically necessary and appropriate treatment for Petitioner’s condition. However, even though whirlpool therapy was medically necessary, Petitioner’s wound did not meet the terms of coverage for whirlpool therapy in his benefit certificate.

Commissioner’s Review

Concerning physical therapy, the Certificate states that such services “do not include….[t]reatment of wounds through hydrotherapy (whirlpool therapy), except in cases of third degree burns….” (BCBSM Benefit Certificate, page 3.4)

Not all medically necessary services are the obligation of an insurer to pay. All health plans have coverage dollar limits and exclusions for certain medical services, whether or not those services and medically necessary. The limitation of coverage for hydrotherapy in the present case is an example. The exclusion is clearly stated and does apply to Petitioner’s treatment. Therefore, the Commissioner finds that BCBSM correctly applied its coverage provisions in this instance.

V
ORDER

Respondent’s November 1, 2002, final adverse determination is upheld.

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.