Bancroft v. THE TECUMSEH PRODUCTS CO.

949 F. Supp. 1294, 1996 WL 737412
CourtDistrict Court, E.D. Michigan
DecidedDecember 20, 1996
DocketCivil Action 95-40466
StatusPublished

This text of 949 F. Supp. 1294 (Bancroft v. THE TECUMSEH PRODUCTS CO.) is published on Counsel Stack Legal Research, covering District Court, E.D. Michigan primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Bancroft v. THE TECUMSEH PRODUCTS CO., 949 F. Supp. 1294, 1996 WL 737412 (E.D. Mich. 1996).

Opinion

MEMORANDUM OPINION AND ORDER GRANTING PLAINTIFFS’ MOTION FOR SUMMARY JUDGMENT AND DENYING DEFENDANT’S MOTION FOR SUMMARY JUDGMENT

GADOLA, District Judge.

This is an action governed by the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq. Before the court are cross-motions for summary judgment pursuant to Federal Rule of Civil Procedure 56(c). Plaintiffs, Violetta and George Bancroft, (“Plaintiffs”), filed their motion for summary judgment on October 18, 1996. The defendant, Teeumseh Products Company, (“Defendant”), also filed its motion for summary ■ judgment on October 18, 1996. Oral argument was heard on December 11, 1996. For the reasons discussed below, this court will grant plaintiffs’ motion *1296 for summary judgment and deny the defendant’s motion for summary judgment.

I.Background

Mrs. Bancroft is a covered beneficiary of the ERISA health benefit plan for hourly retirees that is sponsored by her husband’s employer, Tecumseh Products Company. Prior to corrective surgery plaintiff suffered from macromastia 1 causing severe and chronic back and neck pain, significant stoop, shoulder grooving and paresthesia of the arms. She consulted several physicians, all of whom agreed that her problem could be resolved through a reduction mammaplasty or breast reduction surgery. Plaintiff and her physicians requested coverage for the procedure from the defendant through her husband’s pension plan but were denied because the defendant determined that the procedure was not medically necessary under its interpretation of the plan. 2

Tecumseh Products has designated Aetna Life Insurance Company as its claim administrator. 3 Accordingly, Aetna has been delegated the responsibility for determining whether a requested service is medically necessary.

At the time she submitted her claim for preauthorization, plaintiff was a sixty year old woman with a height of 5'6" and a weight of 218 pounds. On January 27, 1994, Dr. Paul H. Izenberg (“Dr. Izenberg”), plaintiffs surgeon, submitted a request to Tecumseh Products for preauthorization of reduction mammoplasty on behalf of Mrs. Bancroft. Dr. Izenberg’s request indicated that plaintiff exhibited chronic neck and back pain and shoulder grooving, she had difficulty lifting or pinching, that her breast size limited her activity, and that a reduction mammaplasty would relieve those symptoms. Sue Ellen Sedery (“Sedery”) Senior Cost Containment Analyst at Aetna, processed the request and performed Aetna’s initial evaluation of whether breast reduction surgery was medically necessary for Mrs. Bancroft. Ms. Sed-ery consulted Aetna’s on-line system (the “Central Health Policy Library” or “CHPL”) which contains the guidelines that are used by all Aetna employees to evaluate an identified diagnosis for medical necessity. The CHPL guidelines provide for preauthorization or coverage of breast reduction surgery when medical necessity is documented by at least one of the following conditions prior to surgery:

1. severe pain in the breast not relieved by conservative measures (e.g. proper brassiere support) or withdrawal of the cause of the pain and/or drug therapy.
2. severe upper back and/or shoulder pain determined not to be of musculo-skeletal origin (e.g., arthritis, spondyli-tis) and not relieved by an adequate trial of conservative measures (e.g. proper brassiere support, physical therapy, postural modifications, etc.; if the patient is obese, weight loss.)
3. skin breakdown (massive infection, tissue necrosis, slough, ulceration, and/or hemorrhage) overlying breast or infra-mammary fold not relieved or controlled by dermatological treatments and conservative measures.

(emphasis added).

The CHPL guidelines require disapproval of preauthorization or coverage if:

(1) the primary purpose and/or result of the operation is to improve, alter or enhance appearance for psychological, emotional or other reasons;
(2) when the patient is more than 20% over ideal body weight (refer to ideal weight chart in CCM 0089 4 );
*1297 (3) or delivery is imminent in the presence of gigantomastia of pregnancy.

(emphasis added)

Following the provisions set forth in the CHPL guidelines, Ms. Sedery requested the following information from Dr. Izenberg on March 4, 1994: Mrs. Bancroft’s history and physical condition, his office notes, and preoperative photographs. On March 28, 1994, Dr. Izenberg provided Aetna with his office notes and pre-operative photographs. He also informed Aetna that Mrs. Bancroft was 5'6" with a weight of 218 pounds.

After receiving this information, Ms. Sed-ery determined that surgery was not medically necessary because Mrs. Bancroft was more than 20% over her maximum ideal weight as set forth in Claim Committee Minute 089. For this reason, Ms. Sedery denied Mrs. Bancroft’s request for preauthorization in a letter dated April 6,1994.

On June 20, 1994, Aetna received Mrs. Bancroft’s first request for reconsideration of the benefits determination. Along with her request, Mrs. Bancroft provided four letters for review: the letter from Dr. Izenberg that was submitted with her initial request for preauthorization. A letter from James R. Gilsdorf, M.D. (“Dr. Gilsdorf”) a general surgeon, dated April 15, 1994, who had examined plaintiff and stated that he had observed in plaintiff a significant stoop caused by the macromastia, that he had concern regarding the weight of her breasts causing upper extremity paraesthesia, and that her surgery could not be considered- cosmetic. A letter from Anne Benedict of Child & Family Service dated May 4, 1994. A letter from Charles R. Lyon, D.O. (“Dr. Lyon”), dated May 23, 1994, plaintiffs family physician for many years, who stated that plaintiff had chronic back and arm pain for several years, had significant mammary hypertrophy and that the reduction mammaplasty would relieve her back pain. On July 7, 1994, Mrs. Bancroft’s request for preauthorization was referred to Dr. Thomas Felger, an independent medical examiner for consideration of medical necessity. Based upon the materials submitted by plaintiff, Dr. Felger determined that breast reduction surgery was not a medically necessary service, due to Mrs. Bancroft’s weight of 218 pounds. 5 On August 8, 1994, Ms. Sedery again denied Mrs. Bancroft’s request.

On August 9,1994 Tecumseh Products forwarded two additional medical opinions that were allegedly related to plaintiffs breast reduction surgery and again requested reconsideration of Aetna’s decision to deny preauthorization for the surgery. On August 16,1994, Ms. Sedery forwarded the claim file to Dr.

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Bluebook (online)
949 F. Supp. 1294, 1996 WL 737412, Counsel Stack Legal Research, https://law.counselstack.com/opinion/bancroft-v-the-tecumseh-products-co-mied-1996.