Issued and entered January 21, 2003 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On September 19, 2002, XXXXXXXXXXX (Petitioner) 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 (PRIRA), MCL 550.1901 et seq. 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 4, 2002, the Office of Financial Services (OFIS) received from Physicians Health Plan of Mid-Michigan (PHPMM) the information it used to make its adverse determination in Petitioner’s case.

II
FACTUAL BACKGROUND

Petitioner is a PHPMM member covered under the PHPMM Certificate of Coverage. He suffers from Myofascial Pain Syndrome, which was diagnosed by Dr. XXXXXXXXXXX. Petitioner claims he experiences extreme pain from his condition. Petitioner is presently taking Vicodin HP to manage this pain. He says his body has become dependent on and is developing an increasing tolerance to the Vicodin. Petitioner claims that Vicodin is both addictive and harmful to him.

Petitioner’s primary care physician, Dr. XXXXXXXXXX, referred him to the XXXXXXX XXXX XXXXXX. Petitioner claims his prospective coarse of treatment at the XXXXXXXXXXXXX would consist of epidural injections, which would provide him inadequate relief. Petitioner prefers not to go to the pain clinic but would rather receive treatment from Dr. XXXXXXXXXXXXX.

Petitioner indicates Dr. XXXXXXX has previously treated him. Dr. XXXXXXXXX treatment has consisted of heat, manipulation, and acupuncture. Petitioner claims PHPMM previously covered Dr. XXXXXXXXX services because they were being inadvertently incorrectly billed. Petitioner claims that the acupuncture he has received from Dr. XXXXXXX was very effective at treating his condition. Petitioner claims that when the inaccurate billing of Dr. XXXXXXXXX services was corrected, PHPMM ceased its coverage. Petitioner states that he is aware that acupuncture is excluded as a benefit under the PHPMM Certificate of Coverage.

In a letter dated July 11, 2002, Petitioner requested PHPMM make an exception to the terms of his coverage and cover acupuncture treatment for him. In a letter dated July 18, 2002, PHPMM notified Petitioner that his request was denied. Petitioner initiated the internal grievance process on July 23, 2002, and PHPMM reached a final adverse decision in his case on August 16, 2002.

II
ISSUE

Whether PHPMM properly denied Petitioner coverage of acupuncture treatment?

IV
ANALYSIS

Petitioner’s Position

Petitioner believes PHPMM should grant him an exception to the terms of his certificate of coverage and allow him acupuncture benefits. Petitioner claims that Dr. XXXXXXX has provided him with the only effective treatment for his condition, and that Dr. XXXXXXXXX treatment is his only viable option for long-term relief from extreme and chronic pain. Therefore, Petitioner claims that PHPMM should cover acupuncture therapy from Dr. XXXXXXX.

Petitioner supports his position with the following points:

• The XXXXXXXXXXXXXXXXXXX offers no long-terms solutions for his condition.
• He has no surgical options for treating his condition.
• Medicating his pain is only a short-term solution that will only result in addiction and drug tolerance.
• The acetaminophen, from the Vicodin which he is taking, and the Pravachol, which he takes as an anti-cholesterol drug, put stress on his internal organs.
• Acupuncture therapy has been very effective in treating him previously and could provide him with long-term relief from his chronic pain.
• Acupuncture is much less expensive for PHPMM to pay for than the drugs, pain clinic services, and various other medical testing and procedures that are the alternative.

PHPMM’S Position

PHPMM claims in its October 3, 2002, position statement to OFIS as follows:

Acupuncture is expressly excluded from [Petitioner’s] benefit contract.

Within each enrollee’s benefit contract is a list of coverages and exclusions. Acupuncture is expressly excluded from coverage in the benefit contract in Section 11.1 AJ, which states that

“Except as may be specifically provided in Section 10 or through a Rider to the Policy, the following are not Covered:…AJ. Acupuncture; acupressure; hypnotism; rolfing; message therapy; aromatherapy; and other forms of alternative treatment.” (Emphasis added).

The terms of the exclusion are unambiguous and, therefore, should be given effect. There are no provisions within Section 10 related to acupuncture, nor is there an applicable Rider. In the absence of language requiring the coverage, the express exclusion should be given effect.

[Petitioner] states that he had acupuncture performed in the past, and that it has helped his condition. PHPMM reviewed its records and has found no instance where it has paid for the services. If, indeed, [Petitioner] has received acupuncture services in the past and has paid out of pocket for those services, [Petitioner] should reasonably be expected to continue to pay out of pocket without exception to the terms of this benefit contract. [Petitioner] acknowledges in his letter supporting the request for an external review (Attachment I) that he “understand[s] [his] policy specifically excludes acupuncture”, but is requesting an exception. While PHPMM appreciates that [Petitioner] may claim to have experienced some benefits from acupuncture versus traditional treatment, that alone does not compel coverage for acupuncture contrary to the terms of the benefit contract.

Commissioner’s Review

The Commissioner carefully reviewed the arguments and documents presented by the parties in this case. The focus of this analysis is whether PHPMM is obligated by the terms of the PHPMM Certificate of Coverage to expand Petitioner’s benefits to include coverage of acupuncture services. Section 11.1(AJ) of the certificate explicitly excludes acupuncture from coverage, and there is no language in the certificate that requires or provides for an exception to that provision. PHPMM’s denial of coverage for acupuncture services for Petitioner was in complete compliance with the terms of the PHPMM Certificate of Coverage. Therefore, PHPMM’s final adverse determination in Petitioner’s case is valid.

IV
ORDER

Therefore, the Commissioner ORDERS that PHPMM’s August 16, 2002, final adverse determination in this case is upheld. PHPMM is not required to cover acupuncture services for Petitioner.

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 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.