Arbitration Process
Notices of Decision Index



Report Date of Report Comments
129th 07/24/2017 Affirms the Trust's denial of a claim for Seventh Amendment High Level Matrix Compensation based on dual valve surgery performed after the 12/31/2011 eligibility deadline in Seventh Amendment §IX.A.1.a. The Arbitrator rejected Appellant's contention that Court Approved Procedure ('CAP') No. 16 amended the eligibility cut-off for qualifying conditions in §IX.A of the Seventh Amendment. Relying on the district court's Memorandum In Support of PTO 9485, the Arbitrator found that CAP 16 established filing deadlines for otherwise eligible claims and did not amend the substantive eligibility cut-off dates for matrix compensation.
128th 11/17/2016 Compensation for a worsened medical condition is not based on the claimant’s subjective evaluation of what conditions are worse than others. Instead, the Settlement Agreement has defined the range of compensable medical conditions and claimant must meet one of those specific definitions to recover for a worsened medical condition.
127th 10/19/2016 The Trust did not err in denying Seventh Amendment Matrix Benefits at severity level III, where Claimant failed to file a timely claim pursuant to PTO 8559, approving Court Approved Procedure No. 16.

Appeal Ruling Affirming Arbitrator's Decision, PTO 9485

Memorandum In Support of PTO 9485
126th 6/7/2016 Trust did not err in determining that class member did not state a claim for supplemental Seventh Amendment matrix benefits. The "life-long conditions" described by the Green Form and Claimant's physician do not describe any of the medical conditions or events required for level IV or V Seventh Amendment matrix compensation. Trust affirmed.
125th 5/16/2016 Trust did not err in determining that class member did not state a claim for Seventh Amendment matrix benefits. A Seventh Amendment class member is not entitled to severity level V benefits based on ventricular tachycardia where the class member did not actually suffer from an episode of sustained v-tach resulting in hemodynamic compromise. The Settlement Agreement, as amended, provides compensation for medical conditions actually experienced, not those avoided. Trust affirmed.
124nd 3/15/2016 Trust did not err in denying the severity level II claim submitted by Seventh Amendment claimant. Appellant received adequate notice of Seventh Amendment. Trust has no authority to deviate from terms of Settlement Agreement & Seventh Amendment. CAP 16 bars filing of high level claim.  Trust affirmed.
123rd 6/22/2015 Arbitrator determined that Appellant’s claim should have been deemed a Medical Disagreement under the Parallel Processing Procedures and sent to audit. Trust reversed.
122nd 4/23/2015

Claimant did not meet Settlement Agreement requirements for Severity Level IV Claim based upon second surgery, as second surgery was not "through the sternum," as Settlement Agreement unambiguously requires. Trust affirmed.

 

121th 2/25/2015

Trust did not err in determining that Claimant  could not establish eligibility for Matrix Compensation where Claimant did not have echocardiogram study performed prior to close of Screening Period, as mandated by Settlement Agreement. Trust affirmed.

 

Appeal Ruling Affirming Arbitrator’s Decision - PTO 9424 (6/30/15) Foster

 

120th 1/8/15

Trust did not err in determining that Claim was limited to Matrix B, based upon analysis of documentation submitted by the Claimant, including a prior Green Form asserting the presence of a reduction factor. Trust affirmed.

 

Appeal Ruling Affirming Arbitrator’s Decision - PTO 9409 (4/29/15) Muse

 

119th 12/23/14 Trust did not err in determining that Claimant’s Green Form did not support a claim for Matrix Benefits. Trust affirmed.
118th 12/22/14 Arbitrator determined that Claimant met burden of establishing Matrix Claim supported by timely echocardiogram, and therefore submitted a complete claim. Trust reversed.
117th 9/23/14 Claimant failed to provide documentary proof of Diet Drug use. Advertisement for weight loss clinic and copies of checks do not constitute pharmacy or medical records and cannot document Diet Drug use. Physician declaration lacked credibility as it stated that Pondimin and Redux were prescribed concurrently, contrary to medical practice, and because there is no documentation corroborating that physician was associated with the weight loss clinic, much less a prescribing physician. Trust’s Determination Affirmed.
116th 9/8/14

Trust did not err in determining that Appellant's claim was incomplete and not appropriate for Audit. Claimant did not establish that the echocardiogram study submitted to the Trust, labeled "UNKNOWN", was a study of Claimant's heart. Trust’s Determination Affirmed.

Appeal Ruling Reversing (in part) Arbitrator’s Decision - PTO 9388 (1/13/15) Smith

 

115th 6/9/14

Claimant's new evidence failed to document Diet Drug use. Arbitrator found that Trust did not err in determining that newly submitted pages of medical records were not credible. Documentation previously submitted and considered failed to document Diet Drug use for the reasons articulated by the Arbitrator in the 111th Report & Award. Trust’s Determination Affirmed.

Ruling Affirming Arbitrator’s Decision - PTO 9371 (11/5/14) Madkins

 

114th 12/12/2013 Claimant failed to provide documentary proof of Diet Drug use. Claimant did not provide pharmacy/medical records of prescription/dispensing of Diet Drugs. Medical records submitted by Claimant did not document Diet Drug use. Reference to "Fen Phen" does not meet requirement that medical records include Diet Drug name. Unverified letter from the prescribing physician failed to establish proof of use because medical records were not unavailable and the letter was unverified. The letter was further rendered unreliable as it was contradicted by medical records for the period in question. Neither the Trust nor the Arbitrator has the authority to waive the requirements of Settlement Agreement § VI.C.2.d (regarding proof of Diet Drug use). Affidavits/declarations from individuals other than the prescribing physician or dispensing pharmacist do not meet Settlement Agreement requirements. Trust’s Determination Affirmed.
113th 7/5/2013

Claimant did not have conditions required for recovery of Matrix Level III, IV or V Benefits as described by Settlement Agreement and modified by 7th Amendment. To be entitled to Matrix Benefits under the terms of the 7th Amendment, Claimant’s Matrix Event must have occurred on or before 12/31/11. Trust’s Determination Affirmed.

 

112th 4/25/2013

Claimant was more than 79 years of age at time of Matrix Qualifying Event. Settlement Agreement Matrix makes no provisions for Claimants aged 80 years old and older. Trust’s Determination Affirmed. 

 

Appeal Ruling Affirming Arbitrator's Decision - PTO 9350 (9/16/14)

 

111th 12/28/2012

Claimant failed to provide documentary proof of Diet Drug use. Medical records submitted in support of Diet Drug use reflect prescriptions for Fastin (Phentermine) and Phenodrex, neither of which are “Diet Drugs”. Claimant also submitted multiple Blue Form declarations of individuals other than prescribing physician/dispensing pharmacist. Submission of declarations to establish Diet Drug use is permissible only where pharmacy and/or medical records are unobtainable. Declarations of individuals other than prescribing physician/dispensing pharmacist do not establish Diet Drug use, particularly where declarations are contradicted by contemporaneous medical records. Trust’s Determination Affirmed.

 

Arbitration Appeal Ruling Affirming Arbitrator's Decision - PTO 9150 (9/26/13)

 

PTO 9162 (11/13/13) Vacating PTO 9150 and Decision No. 111

110th 12/13/2012

Claimant’s Attesting Physician answered ‘yes’ to  Question E.7 of the GREEN Form (regarding methysergide/ergotamine use), which requires compensation determined by Matrix B, the reduced compensation Matrix. Claimant sought to retract the Attesting Physician’s affirmative answer, seeking payment determined by Matrix A. Settlement Agreement imposes upon Claimants the burden of providing documentation necessary to justify an award of benefits. Contradictory documentation provided by Claimant was insufficient to trump assertions of Attesting Physician(s). Trust’s Determination Affirmed.

109th 10/30/2012

Claimant failed to provide documentary proof of diet drug use in excess of sixty days. Declarations of individuals other than prescribing physician failed to establish proof of use. Declarations of Claimant and spouse cannot establish Diet Drug use, and were found to be self-serving and lacking in credibility. Settlement Agreement Section VI.C.4.b applies only to documentation described in VI.C.4.a; the Trust has no discretion to consider “other supporting documentation” of Diet Drug use other than that set forth in Section VI.C.2.d.(3). Trust’s Final Determination Affirmed.

108th 8/8/2011

Claimant’s pharmacy/medical records supported sixty (60) days of use.  Pharmacy record creates rebuttable presumption of use.  Documentation submitted by Claimant was not “credible proof” that Claimant ingested Diet Drugs for more days than as indicated by pharmacy record, and thus could not rebut presumption created by pharmacy record.  Trust’s Final Determination Affirmed.

Appeal Ruling Affirming Arbitrator's Decision - PTO 9822 (8/8/12)

107th 8/8/2011

Claimant failed to provide documentary proof of diet drug use.  Section VI.C.4.b of the Settlement Agreement is not applicable to proof of Diet Drug use.  Trust’s Final Determination Affirmed.

 

106th 6/24/2010 Claim was properly placed on Matrix B-1, based upon (1) mitral valve prolapse claimed on Green Form and (2) diagnosis of only mild mitral regurgitation in between commencement of Diet Drug use and the close of the Screening Period.  Trust’s Final Determination affirmed.
105th 3/29/2010

Claimant failed to establish Diet Drug use in excess of sixty-one days.  Claim was properly paid on Matrix B-1.  Trust’s findings sustained.

 

103rd 2/9/10

The remedy sought by Appellant, i.e. audit of a Claim determined in the Parallel Processing Procedure, had already been provided via audit of a Supplemental Claim for Matrix Benefits based upon the same echocardiogram.  Failure to contest the Supplemental Determination finding that Claimant’s echocardiogram demonstrates only mild mitral regurgitation constitutes acceptance of said determination.  Trust’s Final Determination affirmed.

Appeal Ruling Affirming Arbitrator's Decision - PTO 8550 (10/22/10)

 102nd  11/19/09

Claimant failed to establish Diet Drug use.  Claimant obtained medications in Mexico.  Because Pondimin & Redux were not sold in Mexico, Claimant therefore did not obtain or ingest Diet Drugs as defined by the Settlement Agreement (i.e., Pondimin or Redux).  Trust’s findings sustained.

 

101st 10/23/09

Claimant failed to (1) demonstrate Diet Drug use and (2) complete a Claim for Matrix Compensation.

Claimant failed to provide documentary proof of Diet Drug use; submitted records failed to include dosage and duration, which information is required by the Settlement Agreement.   Likewise, Claimant failed to submit documentation required to support the representations made by Claimant’s Attesting Physician(s) at Part II of the submitted Green Form(s).   Trust's findings sustained.

100th 9/23/09

Claimant submitted prescription records establishing 60 days of Diet Drug use. Claimant’s own self-serving affidavit submitted in support of the Claim, absent corroboration by other credible evidence, cannot overcome the presumption created by the pharmacy records that Diet Drug use was limited to sixty days.  The fact that Claimant’s prescriptions of Pondimin were filled 43 days provides no evidence as to the manner in which Diet Drugs were ingested. Trust's findings sustained.

99th 9/23/09

Claimant failed to provide documentary proof of Diet Drug use.  Illegible medical records failed to support Diet Drug use.   Unverified letter from a physician other than the prescribing physician did not support Diet Drug use.  Notarized letters from Claimant, Claimant’s spouse, and other individuals failed to support proof of use as (1) medical records were not unobtainable and (2) none was the statement of a prescribing physician/dispensing pharmacist.  Trust’s findings sustained.

98th 4/29/09

Affidavits of Claimant, Claimant’s husband, and a physician other than the prescribing physician failed to establish proof of use.  Declaration of prescribing physician, reporting concurrent use of Pondimin and Redux, was accepted by the Arbitrator based upon timing of ingestion.  Trust’s findings overturned. 

97th 4/21/09

Claimant failed to provide documentary proof of Diet Drug use.  Claimant’s medical records referred to “FenFen,” and as a prospective possibility for future prescription.  Reference to “FenFen” is not necessarily a reference to Pondimin or Redux.  Reference to Redux as possible future prescription cannot be regarded as proof that Claimant was prescribed Diet Drug(s).  The mere receipt of notice of Class Action is not evidence of Diet Drug ingestion.  Trust’s findings sustained.

 

Claimant alleged Diet Drugs were obtained

96th 3/20/09

Claimant failed to provide documentary proof of Diet Drug use.  Diet Drugs obtained by mail order, and through a clinic which had closed and was untraceable.  Affidavits of Claimant’s husband and sister-in-law were not acceptable as proof of Diet Drug use.  The Pink Form does not contractually establish entitlement to Matrix Benefits.  Trust not estopped from requiring Claimant to provide proof of use.  Trust's findings sustained.

Arbitration Appeal Ruling Affirming Arbitrator's Decision - PTO 8276 (9/10/09)
95th 3/12/09

Documentation submitted failed to meet Settlement Agreement requirements to establish proof of Diet Drug use through submission of medical records, as it failed to identify “the date(s) prescribed, the dosage, and the duration the Diet Drug was prescribed.”  Notations of current or past medications do not meet Settlement Agreement requirements and do not constituted a medical record of prescription of Diet Drugs.  Trust's findings sustained.

Arbitration Appeal Ruling Affirming Arbitrator's Decision - PTO 8286 (9/14/09)

94th 3/2/09

Claimant failed to provide documentary proof of Diet Drug ingestion. Purported pharmacy record submitted to the Trust was illegible and failed to establish Diet Drug use.   Trust's findings sustained.

93rd 1/20/09

Claimant failed to provide documentary proof of diet drug ingestion.  Declaration of prescribing physician must identify “the date(s), quantity, frequency, dosage, and number of prescriptions or refills of the Diet Drug(s).”  Notation of Fen-Phen use on an echocardiogram report does not establish proof of use.  Submission of Pondimin pill, absent documentation of provenance, has no probative value.  Mere submission of Green Form Part II does not establish ingestion of Diet Drugs.  Trust's findings sustained.

92nd 1/20/2009

Claimant failed to provide documentary proof of diet drug ingestion.   Claimant alleged Diet Drugs were obtained directly from weight loss clinic.  Affidavit of the Claimant and statement under oath of clinic owner were inadequate to establish Diet Drug use.   Trust's findings sustained.

91st

12/18/2008

Claimant sought Matrix Level II Benefits, however Claimant's Green form has failed to allege any condition that would make her eligible for Matrix benefits.  Trust's findings sustained.

Arbitration Appeal Ruling Affirming Arbitrator's Decision - PTO 8267 (8/28/09)

90th

11/18/08

Claimant failed to provide documentary proof of diet drug ingestion as required by the Settlement Agreement. Affidavits of the Claimant and individuals other than a prescribing physician/dispensing pharmacist were inadequate to establish Diet Drug use. Arbitrator rejected Claimant’s argument of detrimental reliance. The Trust has no authority to waive Settlement Agreement requirements that Claimant submit proof of use. Trust’s findings affirmed.

Arbitration Appeal Ruling Affirming Arbitrator's Decision - PTO 8289 (9/17/09)

89th

11/13/08

Claimant failed to provide documentary proof of diet drug ingestion as required by the Settlement Agreement. Trust’s findings affirmed.
88th

10/28/08

Green Form does not support a Claim for Matrix Benefits at Severity II or Severity I. Although Attesting Physician answered in the affirmative to Question F.1, regarding endocardial fibrosis, in the absence of supporting medical records or other evidence of the condition, Claimant failed to establish eligibility for Matrix Benefits. Trust’s findings affirmed.
87th 10/15/08

Claimant failed to provide documentary proof of diet drug ingestion as required by the Settlement Agreement. (Claimant’s prescribing physician deceased and pharmacy destroyed by fire.) Trust’s findings affirmed.

Arbitration Appeal Ruling Affirming Arbitrator's Decision - PTO 8127 (4/1/09)
86th 5/21/08

Claim was denied for failure to provide adequate proof of Diet Drug ingestion pursuant to Section VI.C.2.d. (3).  Where a Claimant is unable to provide pharmacy records, a Claimant may provide an affidavit, under penalty of perjury from the prescribing physician or pharmacist but that affidavit must identity the Claimant, the drug prescribed or dispensed, that date(s), quantity, frequency, dosage and number of prescriptions or refills of the diet drugs. An affidavit from a prescribing physician failing to set forth: any dosages of the diet drug dispensed, the dates of which the diet drug were dispensed and a description of the usage that does not include quantity, frequency or the number of prescriptions or refills of the diet drug does not meet the requirements of the Settlement Agreement. Trust's findings sustained.

85th 11/29/07

Claimant was denied for failure to provide adequate proof of ingestion. Claimant argued that she could not acquire records because the prescribing physician is deceased. Claimant further argued that because she was paid a Fund A benefit, she had established adequate proof of Diet Drug use. Arbitrator reiterated that the Trust must adhere to the Settlement Agreement requirements for drug proof and that the Trust will not be estopped from denying benefits for lack of drug proof based on prior payment of another benefit. Trust findings sustained. 

Arbitration Appeal Ruling Affirming Arbitrator's Decision - PTO 8134 (4/6/09

84th 10/15/07 GREEN Form reflects mild mitral and mild aortic regurgitation. Claimant is not qualified to receive Matrix Level benefits because the conditions required for recovery on Levels I-V are not present. Trust findings sustained.
83rd 7/19/07 In lieu of pharmacy records, medical records or the affidavit of a physician or dispensing pharmacy, Claimant submitted copies of checks to a diet clinic, a letter from said clinic that records were not available, and an email to a pharmacy requesting records, with a reply from the pharmacy, reflecting anattempt to obtain records. These records do not constitute pharmacy records, or the medical records of a physician who prescribed or dispensed diet drugs.  Additionally, an affidavit from Claimant's spouse does not qualify as an affidavit under penalty of pergury from a prescribing physician or dispensing pharmacy identifying the claimant, the drug prescribed or dispensed, the date(s), quantity, frequency, dosage and number of prescriptions or refills of the diet drug(s) to document ingestion. The Claimant failed to provide documentary proof of diet drug ingestion as required by the Settlement Agreement. Trust's findings sustained.
82nd 5/30/07

Green Form reflects no mitral and mild aortic regurgitation. Claimant is not entitled to benefits because she does not have a Qualifying Condition. Trust's findings sustained.

Arbitration Appeal Ruling Affirming Arbitrator's Decision - PTO 8133 (4/6/09)

81st 5/29/07 Claimant passed away before having echocardiogram performed. A Diet Drug Recipient must be both eligible and qualified. Neither alone is sufficient. In order to be eligible for Matrix Compensation, a Claimant must fit within two categories: (1) DDRs diagnosed by a Qualified Physician as FDA positive or as having mild mitral regurgitationby an echocardiogram performed on or before 1/03/03... or (2) DDRs who... have been diagnosed by a Qualified Physician as having Endocardial Fibrosis... Claimant does not meet either criteria. As such, Claimant is not eligible for Matrix Compensation Benefits. Based on the Attesting Physician's responses to the Green Form answers, the arbitrator found that the Claimant was also not Qualified for Matrix Compensation Benefits. Trust's findings sustained.
80th 5/29/07

Affidavits from Claimant, Claimant's mother, Claimant's co-worker, and physician who was not prescribing physician do not comply with the Settlement Agreement's requirements for establishing proof of either Pondimin or Redux use. Personal declarations of Diet Drug use are inadequate for establishing either the fact or duration of Diet Drug ingestion. Prescribing physician submitted declaration that was inconsistant with the other affidavits and ambiguous. Arbitrator  states that the mere submission of a declaration or affidavit by a dispensing physician does not in itself suffice to meet the requirements of subsection (3) of the SA's requirements for establishing proof of Diet Drug use. The declaration must be unambiguous and comply with the timeframe of when the diet drugs were on the market. Trust's findings sustained.

79th 4/24/07 Claimant submitted a pharmacy record showing one prescription for Pondimin. The pharmacy record states the quantity of pills dispensed was one hundred (100) pills with an instruction to take (1) one tablet (3) times per day. This record established thirty-three (33) days of diet drug use. Where the records are not unobtainable, a claimant's signed declaration will not be considered.  The Trust was correct in relying on the pharmacy records. Trust's findings sustained. Claimant is eligible for Matrix Compensation on Matrix B-1.
78th 3/19/07 Green form reflects presence of aortic stenosis with an aortic valve area < 1.0 square centimeter by the Continuity Equation (Question D.5) and mild or greater aortic regurgitation confiirmed by echocardiogram prior to Pondimin (Question E.4). Assignment to Matrix B-1 appropriate. Trust findings sustained.
77th 2/14/07 Claimant submitted prescription records establishing 60 days use of Redux. Ambiguous medical records do not overcome the pharmacy records' presumption that Redux use was limited to sixty. Trust's findings sustained. Claimant is entitled to Matrix compensation on Matrix B.
76th 11/14/06 GREEN form reflects no mitral or aortic regurgitation. Claimant is not FDA+ and has not established a Matrix Claim. Trust findings sustained.
75th 10/5/06 In the case of Mitral Valve Prolapse and Mitral Annular Calcification, assignment to B-1 Matrix is unaffected by the time at which the condition appears or is diagnosed. Trust findings sustained.
74th 9/10/06 A notation on a prescription pad does not constitute an affidavit under penalty of perjury and is not enough to rebut the presumption established by the pharmacy records themselves. Trust's findings sustained. Claimant is entitled to Matrix Compensation on Matrix B.
73rd 3/24/06 A discharged attorney has no right to attorney's contigent fees where no recovery is obtained prior to the discharge.  Current attorney is solely entitled to attorney's fee. Trust's findings sustained.
72nd 01/03/06 The Arbitrator permitted the admission of new evidence enabling Claimant to provide credible proof that she ingested diet drugs for 61 days or more, thereby qualifying her for Matrix Benefits under Matrix A rather than Matrix B.  Remanded the claim  to the Trust to be determined under Matrix A.
71st 12/26/05 GREEN Form reflects severe mitral and no aortic regurgitation.  Claimant underwent Mitral Valve Replacement surgery and is entitled to Matrix Level III benefit.  The benefit is properly reduced to the B-Matrix level because Claimant suffered from Mitral Valve Prolapse and Mitral Annular Calcification.  GRAY Form addresses only levels of mitral and aortic valve regurgitation and does not include any evaluation of other medical conditions which might indicate Matrix or severity level.  Claimant qualifies for Matrix Level III benefit based on his age at the date of surgery.  Trust’s findings sustained.
70th 11/30/05 Green Form reflects no mitral regurgitation and mild aortic regurgitation, with no other conditions alleged.  Claimant is not entitled to Matrix-Level Benefits because the conditions that are required for recovery of Matrix Level Benefits are not present in this claim.  Presence or absence of aortic sclerosis is irrelevant.  Trust’s findings sustained.
69th 11/30/05 GREEN Form reflects moderate mitral and no aortic regurgitation.  Claimant is not currently qualified to receive Matrix-Level benefits because the conditions required for recovery on Levels I-V are not currently present.  Trust’s findings sustained.
68th 11/30/05 GREEN Form reflects mild mitral and moderate aortic regurgitation.  Claimant does suffer from moderate aortic regurgitation.  However, claimant does not suffer from any condition associated with moderate aortic regurgitation, which is a prerequisite to recovery.  Trust’s findings sustained.
67th 11/30/05

GREEN Form reflects mild mitral and mild aortic regurgitation.  Both echocardiogram and GREEN Form indicate that claimant is FDA+.  Claimant is not currently qualified to receive Matrix-Level benefits because the conditions required for recovery on Levels I-V are not present.  Trust’s findings sustained.

66th 11/29/05 GREEN Form reflects mild mitral and no aortic regurgitation.  A positive response to Question F.5. qualifies a Diet Drug recipient for Matrix-level benefits only if the claimant first demonstrates that they suffered from moderate or severe mitral regurgitation.  Abnormal left atrial supero inferior systolic dimension or abnormal left atrial antero-posterior systolic dimension does not alone qualify claimant for Matrix-Level benefits.  Use of the word “shall” in Section IV.B.1.a of the Settlement Agreement does not provide entitlement to Matrix compensation.  Trust’s findings sustained.
65th 11/29/05 GREEN Form reflects mild mitral and no aortic regurgitation.  In addition to being eligible for Matrix benefits, in order to receive Matrix compensation a claimant must also have a qualifying disease.  Claimant is not currently entitled to Matrix-Level Benefits because the conditions that are required for recovery of Matrix Level I, II, III, IV or V Benefits are not present in this claim.  Trust’s findings sustained.
64th 11/29/05 Claimant sought Matrix Level A-I Benefits.  GREEN Form reflects mild mitral and mild aortic regurgitation.  Neither echocardiogram reports contain a finding that claimant suffered any regurgitation.  This lack of corroboration is immaterial.  Trust does not dispute GREEN Form assertions.  Claimant is not currently qualified to receive Matrix-Level benefits because the conditions required for recovery on Levels I-V are not present.  Trust’s findings sustained.
63rd 11/14/05

Neither estoppel nor detrimental reliance arguments preclude the Trust from denying claim for Matrix Benefits at Level A-II on the ground of failure to provide documentary proof of diet drug usage and ingestion.  Trust’s findings sustained.

62nd 11/02/05 Supplemental GREEN Form reflects mild mitral and mild aortic regurgitation.  Claimant is not entitled to Matrix Benefits because the Claimant does not  have a qualifying condition.  Claimant may later qualify for Matrix Level benefits if her condition becomes more severe in ways that are defined by the Settlement Agreement.  Trust’s findings sustained.
61st 11/02/05 GREEN Form reflects no mitral and mild aortic regurgitation.  Claimant is not entitled to Matrix Benefits because the Claimant does not  have a qualifying condition.  Claimant may later qualify for Matrix Level benefits if her condition becomes more severe in ways that are defined by the Settlement Agreement.  Fund A issues are not covered by the Arbitration process.  Trust's findings sustained.
60th 11/02/05 GREEN Form reflects no mitral and mild aortic regurgitation.  Claimant is not entitled to Matrix Benefits because the Claimant does not  have a qualifying condition.  Claimant may later qualify for Matrix Level benefits if her condition becomes more severe in ways that are defined by the Settlement Agreement.  Fund A issues are not covered by the Arbitration process.  Trust's findings sustained. 
59th 10/26/05 GREEN Form reflects mild mitral and no aortic regurgitation.  GREEN Form also reports a complicating medical condition in response to Question F-5 of Part II.  At the time of the echocardiogram the claimant was 81 years of age.  The Settlement Agreement, as amended, states that a Claimant must have been diagnosed with an FDA+ condition prior to the age of 80.  Fund A issues are not covered by the Arbitration process. Trust's findings sustained.
58th 10/25/05 Claimant sought Matrix Level A-I Benefits.  GREEN Form reflects mild mitral and mild aortic regurgitation.  Neither echocardiograms contain a finding that claimant suffered any aortic regurgitation.  Omission is not significant.  GREEN Form states that claimant does not suffer from severe aortic or mitral regurgitation, nor FDA+ valvular regurgitation with bacterial endocarditis.  Claimant is not currently qualified to receive Matrix-Level benefits because the conditions required for recovery on Levels I-V are not present.  Trust’s findings sustained.
57th 10/25/05 Claimant sought Matrix Level A-I Benefits.  GREEN Form reflects mild mitral and mild aortic regurgitation.  GREEN Form states that claimant does not suffer from severe aortic or mitral regurgitation, nor FDA+ valvular regurgitation with bacterial endocarditis.  GREEN Form does not establish that claimant is qualified to receive Matrix-Level benefits.  Trust’s findings sustained.
56th 10/14/05 GREEN Form reflects mild mitral and mild aortic regurgitation.  Claimant is FDA+ but fails to establish a Matrix Level claim because the Claimant does not  have a qualifying condition in addition to being FDA+.  Trust’s findings sustained.
55th 10/14/05 GREEN Form reflects moderate mitral and mild aortic regurgitation.  GREEN Form further establishes that claimant has abnormal left ventricular end-systolic dimension, but in order for this to qualify claimant for Matrix Level II Benefits it must be accompanied by moderate or severe aortic valve regurgitation, which it is not.  Trust’s findings sustained. 
54th 10/14/05 GREEN Form reflects moderate mitral and no aortic regurgitation.  Claimant is FDA+ but fails to establish a Matrix Level claim because the Claimant does not  have a qualifying condition in addition to being FDA+.  Trust’s findings sustained.
53rd 07/25/05 Claimant sought Matrix Level III benefits on the grounds that she suffered a stroke due to bacterial endocarditis after ingestion of diet drugs.  Claimant is not entitled to Matrix III benefits because a diagnosis of FDA positive must precede the qualifying medical condition, which in this case was a stroke.  Trust findings sustained.
52nd 10/28/04 GREEN Form reflects mild mitral regurgitation and no aortic regurgitation. Claimant is not FDA+. For this reason, Matrix Benefits are not warranted. Trust's findings sustained.
51st 09/17/04 GREEN form reflects no mitral and no aortic regurgitation.  GRAY form reflects no mitral and no aortic regurgitation.  GRAY form #2 reflects no mitral and no aortic regurgitation.  Claimant is not FDA+ and does not establish a Matrix level claim at this time.  Trust's findings sustained.
50th 09/16/04 Claimant was FDA+ with both moderate mitral and aortic regurgitation but has no complicating factors that establish a Matrix level claim.  Trust's determinations sustained.
49th 09/13/04 GREEN form reflects no mitral and no aortic regurgitation.  In order for the Claimant to be eligible for Matrix level benefits the Claimant must submit an echocardiogram report and tape.  The burden of providing medical records does not shift to the Trust upon submission of a GREEN Form.  The Claimant is not FDA+ and does not establish a Matrix level claim at this time.  Trust's findings sustained.
48th 09/08/04 GREEN form reflects no mitral and mild aortic regurgitation.  Claimant is FDA+ but fails to establish a Matrix level claim because they do not have a qualifying condition in addition to being FDA+.  Trust's findings sustained.
47th 08/30/04 GREEN Form reflects mild mitral regurgitation and no aortic regurgitation . Claimant is not FDA+. For this reason, Matrix Benefits are not warranted. Trust's findings sustained.
46th 08/19/04

Claimant has the burden to establish proof of drug use.  An affidavit by the claimant and medical notes claiming the reason for study "phen phen use," is not enough to meet this burden.  The Trust is only required to reimburse one echocardiogram per claimant.  Trust's findings sustained.

45th 08/16/04

Claimant sought Matrix level V benefits. GREEN Form is not FDA+ (no mitral regurgitation and no aortic regurgitation).  Claimant's green form has failed to allege any qualifying condition that would make her eligible for Matrix benefits.  Trust's findings sustained.

44th 08/13/04 GREEN form reflects no mitral or aortic regurgitation.  Gray II reflects mild mitral regurgitation only.  Claimant is not FDA+ and does not establish a Matrix claim.  Trust's findings sustained.
43rd 05/26/04 GREEN form reflects no mitral and moderate aortic regurgitation.  GRAY form reflects mild mitral and moderate aortic regurgitation.  Claimant is FDA+. Claimant does not establish a Matrix level claim because they do not have a qualifying condition in addition to being FDA+.  Trust's findings sustained.
42nd 05/17/04 GREEN form reflects no mitral regurgitation and no aortic regurgitation.  Claimant is not FDA+ and does not establish a Matrix level claim at this time.  Trust's findings sustained.
41st 05/10/04 Green Form reflects mild mitral regurgitation and no aortic regurgitation. For this reason, Matrix Benefits are not warranted. Trust's findings sustained.
40th 04/22/04 (2) GREEN form reflects no mitral and no aortic regurgitation.  Claimant is not FDA+ and does not establish a Matrix level claim at this time.  Trust's findings sustained.
39th 04/22/04 (1) Mild mitral and no aortic regurgitation do not warrant Matrix Benefits.  Trust's findings sustained.
38th 04/14/04

Claimant sought Matrix Benefits, her GREEN Form failed to allege any condition that would make her eligible for either an A-Level or B-Level benefit.  Her echocardiograms did not reveal any level of regurgitation. The Trust denied a Matrix benefit; the Arbitrator confirmed the Trust’s determination.

37th 04/13/04 Claimant’s echocardiogram at the time of surgery reflected a Myocardial Infarction (MI); after surgery Claimant died.  The GREEN Form filed by Claimant’s estate answered that Claimant had reduction factors, MI and mitral annular calcification (MAC), at the time the echocardiogram was taken.  The Trust awarded benefits at the B-V level due to the reduction factors.  The Estate argued that the MI could have been a sign of Mitral Valve Regurgitation (MR), which may have supported an A-Level benefit.  The Arbitrator ruled that the reduction factor, MAC, was present, whether or not MR could have caused the infarction; therefore, the B-Level benefit was proper.   The Trust’s determination was affirmed.
36th

10/22/02

Claimant appealed the Trust's determination to award benefits on the B-Matrix at Level IV rather than on the A-Matrix.  The Arbitrator determined that the Trust’s decision to award benefits on the B-Matrix Level IV, in light of ambiguous and contradictory answers and information in Part II of the GREEN Form, a Supplemental GREEN Form, and other medical documentation) was not clearly erroneous.  The Trust's review of the medical records resulted in the determination, which was held not to be clearly erroneous, that the Claimant is to be paid on the B-Matrix because his condition of acute mitral regurgitation was associated with acute myocardial infarction.  The condition of acute mitral regurgitation was not shown by the answers on any GREEN Form submission or other submission of the Claimant to have preceded the myocardial infarction.
35th

10/14/02

Claimant filed three GREEN Forms and two GRAY Forms, none of which conclusively find that Claimant is FDA+.  At hearing, Claimant asserted a diagnosis of endocardial fibrosis on the basis of a saliva test.  The Settlement Agreement requires diagnosis of endocardial fibrosis through either endomyocardial biopsy and cardiac catheterization or autopsy, and a saliva test cannot substitute.  Trust determination sustained.
34th 10/10/02 GREEN form reflects no mitral and no aortic regurgitation.  Claimant is not FDA+ and does not establish a Matrix level claim at this time.  Trust's findings sustained.
33rd

10/9/02

Claimant sought a Matrix A, Level V benefit based on Moderate MR and Mild AR, plus the aggravating condition of ventricular fibrillation or sustained ventricular tachycardia (“aggravating factors”).  Claimant had a history of the aggravating factors, but a cardiac catheterization at the time of a myocardial infarction showed no regurgitation (not FDA+).  The Auditing Cardiologist found no aggravating factors at the time of the FDA+ echocardiogram.  Claimant argued that Settlement Agreement permits a history of   aggravating factors at any time to result in a Level V benefit.  The Arbitrator held that the aggravating factors must be present at the time an FDA+ diagnosis is made, not at an unrelated time in the past.  Claimant did not have aggravating factors present at the time the FDA+ echocardiogram was taken, and a Level V benefit was not warranted.  Trust determination sustained.
32nd 09/17/02 Claimant sought Matrix B, Level III benefits based on aortic valve replacement and the presence of aortic stenosis with an aortic valve area < 1 sq. cm.  Because the valve replacement surgery was due to aortic stenosis (not left-sided valvular heart disease due to the ingestion of PondiminÒ and/or ReduxÔ), the Trust properly denied benefits at this time.  Trust’s determination sustained.
31st 08/23/02 This Report also explains the standards for evaluating evidence [e.g., Claimant's and physician's affidavits, increased dosage, weight-loss] adduced to support ingestion of a diet Drug 61+ days. [See, Report 27.] Claimant received a final determination for a benefit at Matrix-B, Level II, reduced due to ingestion of # 60 days. The Arbitrator rejected, as proof of longer duration of ingestion, evidence that Claimant received a higher dosage, that Claimant took less than the prescribed dosage to avoid sleeplessness, that Claimant's physician attested that hundreds of patients were taking less than prescribed dosages, and Claimant's own affidavits of ingestion 61 days. The Arbitrator stated the standard of review for overturning Trust determinations as requiring a finding of clearly erroneous determinations. Trust's determinations sustained.
30th 08/14/02 Claimant has mild mitral regurgitation and no aortic regurgitation.  Claimant had aortic valve replacement surgery but since there was no aortic regurgitation noted and this was elective surgery due to aortic stenosis, he is not eligible for Matrix Benefits.  Trust's findings sustained.  (See also 10th Decision of 3/1/02.)
29th 07/20/02 GREEN form was not completed by a Board-Certified Cardiologist or Cardiothoracic Surgeon with Level 2 training in echocardiography and reflects only mild mitral and no aortic regurgitation.  The GREEN form violates the requirements of the Settlement Agreement.  The claimant is not FDA+ and does not establish a Matrix level claim at this time.  Trust's findings sustained.
28th 07/17/02 Deceased Claimant's Surviving Spouse sought Matrix compensation benefits at Matrix-A, Level V. Decedent's medical records reflect mild MR, mild AR, and death due to congestive heart failure. Decedent was cremated. The Arbitrator rejected the Representative Claimant's argument that strong circumstantial evidence that Decedent's severe heart problems were due to the ingestion of a Diet Drug. There is no indication in the record of a medical condition which can support a Matrix level benefit. Trust's determinations sustained. Trust's request for costs and fees denied.
27th 07/10/02 This Report articulates standards for evaluating the totality of circumstances@ where an affidavit is submitted to substantiate drug ingestion over 60 days. Claimant received a final determination of a Matrix-B, Level II benefit [based on drug ingestion # 60 days, moderate MR, and pulmonary hypertension secondary to VHD]. Pharmacy records support 60 days usage, and not more. The Arbitrator articulates a four-point totality of circumstances@ test for evaluating Claimant's own affidavit. The Arbitrator rejected Claimant's theory that patients commonly skip or reduce ingestion of prescribed dosages, and therefore it should be presumed that Claimant ingested the Diet Drug for 61+ days. An adult child, living independently at a separate address, is not a Derivative Claimant as defined by the Settlement Agreement. Trust's determinations sustained. Trust's request for costs and fees denied.
26th 06/21/02 Claimant's Supplemental GREEN Form, Part II, reports no MR and no AR. The first Echo report indicates no MR and trivial AR. A second Echo report, in support of the Supplemental Form, reflects mild MR. Based on any of the above, Claimant is not eligible for Matrix Level benefits at this time. Trust's determinations sustained.
25th 06/04/02 GREEN Form reflects mild mitral and mild aortic regurgitation.  Claimant is not currently qualified to receive Matrix-Level benefits because the conditions required for recovery on Levels I-V are not present.  Trust’s findings sustained.
24th 06/03/02 Claimant, who underwent Mitral Valve Replacement surgery, is entitled to a Matrix Level III benefit. Because Claimant experienced Mitral Valve Prolapse, and there is evidence of ruptured chordae tendineae, a benefit reduced to the B-Matrix Level is proper. An erroneous initial Trust determination of a benefit at the Matrix-A level cannot stop the Trust from awarding benefits at the B-Level. Trust's determinations sustained.
23rd 05/30/02 GREEN Form reflects no mitral and moderate aortic regurgitation. Claimant has an ejection fraction of 50-60%.  Claimant’s GREEN Form does not indicate they have any condition associated with their aortic or mitral valve that currently qualifies them for any Matrix-Level Benefits.  Trust's findings sustained. 
22nd 05/13/02 Claimant has Mild MR, an ejection fraction of 50%, and no aortic regurgitation. Claimant does not qualify for Matrix Level benefits at this time. Claimant is registered, and may file a later Claim based on worsened conditions consistent with the Settlement Agreement. [The issues in this Report largely are repetitive of those presented in Reports 4, 5, and 16.]
21st 05/15/02 Claimant [61+ days ingestion, Moderate MR only] does not qualify for a Matrix Level I benefit. Claimant does not qualify for Matrix Level II benefits. While there is a presence of MR, there are not complicating factors. Trust's determination sustained.
20th 05/30/02 Claimant is FDA+ (moderate AR, 50%-60% EF), with no complicating factors. Claimant's physician stated "unequivocally" that Claimant will develop valvular heart disease in the future. That Claimant in the future may develop more serious VHD does not currently qualify Claimant for a Matrix Level benefit. Trust's determination sustained.
19th 05/09/02 GREEN form reflects mild mitral and no aortic regurgitation.  Claimant is not FDA+ and does not establish a Matrix level claim at this time.  Trust's findings sustained.
18th 4/25/02 Echo report reflects only mild aortic insufficiency (LV ejection fraction 56%). The GREEN Form reports moderate aortic regurgitation and pulmonary hypertension. Claimant is not eligible for Matrix Level benefits at this time. Matrix Level I requires severe aortic or mitral regurgitation. Matrix Level II requires moderate or severe aortic or severe mitral regurgitation with complicating factors, which are not present at this time. As one alternate ground for relief, a Matrix Level II(a) Claim requires severe aortic regurgitation with secondary pulmonary hypertension; mild aortic insufficiency will not sustain a pulmonary hypertension claim. Trust's findings sustained.
17th 5/02/02 Claimant [61+ days ingestion, Moderate AR only] does not qualify for a Matrix Level I benefit. Claimant does not qualify for Matrix Level II benefits. While there is a presence of AR, there are not complicating factors. Trust's determination sustained.
16th 4/22/02 GREEN Form reflects only mild aortic (ejection fraction 55%) and no mitral valve regurgitation. Claimant is not eligible for Matrix Level benefits at this time. Fund A issues are not subject to the Arbitration Process. Trust's findings sustained.
15th 4/10/02 GREEN Form reflects mild mitral regurgitation and no aortic regurgitation . For this reason, Matrix Benefits are not warranted. Trust's findings sustained.
14th 3/22/02 GREEN Form reflects only mild mitral and no aortic valve regurgitation. Claimant underwent valve replacement surgery, but this surgery was due to aortic stenosis. Claimant is not FDA+ at this time, and the valve replacement surgery does not establish a Matrix Level Claim. Trust's findings sustained.
13th 3/22/02 GREEN Forms, submitted first by non-Board-Certified or eligible physician, then by Board-eligible physician, do not support Matrix-Level Benefits at this time. Request for drug reimbursement should be directed to the Trust. Trust's findings sustained.
12th 3/12/02 GREEN Form: 1) F.8, reported ejection fraction of 50%-60% and, 2) no pulmonary hypertension secondary to severe AVR, or to moderate or higher MVR. Later unsworn letter of Doctor, reporting at least moderate mitral regurgitation and pulmonary hypertension, is insufficient to support Matrix Benefits. Trust's reliance on GREEN Form answers sustained.
11th 3/06/02 Claimant FDA+, but mild mitral and mild aortic regurgitation do not support Matrix Benefits. Trust's findings sustained.
10th 3/01/02 Elective aortic valve replacement. Aortic stenosis and post-op infection. Mild mitral and trace/mild aortic regurgitation do not support Matrix Benefits. Record left open.  (Trust's findings in this matter were sustained in the 30th Decision of 8/14/02 below.)
9th 3/01/02 Mild mitral and mild aortic regurgitation do not qualify for Matrix Benefits. Trust's findings sustained.
8th 3/01/02 Echocardiogram and GREEN Form show Claimant is not FDA+. Trust's findings sustained.
7th 2/19/02 Inexact forms are considered. Only mild aortic regurgitation does not warrant Matrix Benefits. Trust's findings sustained.
6th 2/20/02 Less than mild mitral and aortic regurgitation do not warrant Matrix Benefits. Trust's findings sustained.
5th 2/19/02 Mild mitral and no aortic regurgitation do not warrant Matrix Benefits. Class "Eligibility" does not mean "Qualified" for Matrix Benefits. Trust's findings sustained.
4th 2/15/02 Mild mitral and lower than mild aortic regurgitation do no warrant Matrix Benefits. Trust's findings sustained.
3rd 1/21/02 Mild aortic regurgitation is reflected in the GREEN Form, Question C.3.b. (on page 8). Claimant not entitled to matrix benefits at this time. Trust's findings sustained.
2nd 1/21/02 No mitral regurgitation. No aortic regurgitation. Cross-out creates no ambiguity. Trust's findings sustained.
1st 12/14/01 Trivial mitral regurgitation. No aortic regurgitation. Trust's findings sustained.



 
  Terms of Use / Privacy Policy
Case/Med Benefit Reimbursement for Certain Privately-Obtained Echocardiograms Preservation of Matrix Claim benefits Intermediate Opt-Out (with exceptions per Fifth Amendment Back-End Opt-Out (with exceptions per Fifth Amendment) End of Exceptions for Screening Program Provided by Fifth Amendment Endocardial Fibrosis