Opinion ID: 3014369
Heading Depth: 2
Heading Rank: 1

Heading: these treatments met with only temporary

Text: relief, Dr. Donald J. Macher, an oral Stratton had health insurance surgeon, suggested that Stratton undergo through an employer-sponsored health arthroplasty surgery for her TMJ. The plan of DuPont, her husband’s employer. full medical term for this surgery is The plan covering Stratton excludes “Right and Left Temporomandibular “[c]harges for services or supplies not Joint Reconstructive Arthroplasty,” J. medically necessary for the diagnosis and App. at 156, and it is an invasive treatment of the illness or injury.” J. procedure that involves repositioning App. at 26.2 It defines the term discs, lysis of adhesions, and the “medically necessary” as a “service or insertion of a previously constructed supply which is reasonable and necessary splint into the mouth. for the diagnosis or treatment of an illness or injury, in view of the customary On or about November 13, 1999, practice in the geographical area, and is Aetna initially denied coverage for the given at the appropriate level of care.” J. surgery but in late December requested App. at 15. It is undisputed that first that Stratton submit an updated magnetic Aetna U.S. Healthcare (“Aetna”), the resonance image (“MRI”) so that her insurance carrier for DuPont, and request could be further considered. The ultimately DuPont had discretion to most recent MRI in Stratton’s record administer the plan with regard to until that date was taken February 8, medically necessary services and 1990; at Aetna’s request, Stratton supplies. obtained an updated MRI on January 3, 2000. Stratton submitted the updated The facts set forth hereafter are MRI, which a specialist at Aetna, Dr. taken from the record on the summary George Koumaras, reviewed. On judgment motion and are not in dispute. January 6, 2000, Aetna denied coverage In 1990, Stratton’s doctors for the requested surgery on the ground diagnosed her with TMJ, and for the next that there were more conservative and ten years she suffered from headaches medically appropriate treatments and the inability to open and close her available, such as arthrocentesis or mouth, chew, yawn, and laugh without arthroscopic surgery. Arthrocentesis pain. She underwent many forms of involves anesthetizing the affected TMJ conservative treatment, including splint and then flushing the joint with a sterile therapy, orthodontia, dental work, solution to lubricate the joint surfaces analgesics and muscle relaxants. After and reduce inflammation, see American Academy of Orofacial Pain, at http://www.aaop.org/info_arthro.htm; 2 We use “J. App.” to cite to the arthroscopy involves inserting an Joint Appendix, and “App.” to cite to imaging and therapy device into the