Court Denies Claim for Plastic Surgery Benefits after Gastric Bypass

The court rejected Laura Murray’s argument that IBM’s rejection of her claims for the second set of surgeries was unreasonable because it was inconsistent with its previous decision to provide coverage for the first set of surgeries. Murray claimed that IBM applied a higher standard to the second approval request, even though the “merits for the second surgeries [were] the same for the primary surgery.”

The court pointed out that under guidelines of the American Standards for Plastic Surgery (ASPS) guidelines, symptoms indicating medical necessity may be present in one part of the body but not in another. The court also pointed out that IBM’s self-insured plan requires proof that reasonable attempts at conservative treatments failed, and ruled that Murray had not provided evidence of this.

In its opinion, the district court ntoed that evaluating the medical necessity of each set of surgeries separately was reasonable and proper in light of the accepted medical standards. “IBM’s decision that the first set of surgeries was medically necessary but that the second set of surgeries was not does not constitute an inconsistent application of the plan,” the opinion stated.

Murray also argued   that the plan administrator’s decision to deny benefits was unsupported by substantial evidence because it relied on the opinion of an independent medical review firm rather than the opinions of Murray’s treating physicians. Citing a previous court decision, the district court noted “a plan need not accord the insured’s treating physician greater deference than a plan’s retained physician. Although plan administrators may not ‘arbitrarily refuse’ to credit the reliable evidence put forth by a claimant, there is no ‘heightened burden of explanation . . . when they reject a treating physician’s opinion.'”

The court said the file reveals that IBM’s decision to deny coverage was supported by substantial evidence.

The opinion is here .