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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 07-0006 – September 19, 2007
Trustees: Micheal W. Buckner, A. Frank Dunham, Michael H. Holland, and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
Background Facts
Complainant’s dentist and primary care physician both recommend that Complainant have his remaining teeth extracted due to advanced periodontal disease and generalized tooth decay. Complainant suffers from multiple medical problems, including insulin dependent type 2 diabetes, hypertension, hyperlipidemia, grade III hepatitis C, and asplenism, that, in the opinion of Complainant’s primary care physician, have been significant contributing factors to Complainant’s periodontal and tooth disease. Respondent has referred Complainant to the Dental Plan and maintains that the requested procedures are not covered under the Employer Benefit Plan.
Dispute
Is the Respondent required to provide coverage for the Complainant’s dental work under the Employer Benefit Plan?
Positions of the Parties
Position of the Complainant: Complainant’s underlying medical conditions, which are covered under the Employer Benefit Plan, are causing the dental and periodontal disease. As such, the dental work requested by the Complainant’s dentist and primary care physician should also be covered by the Employer Benefit Plan.
Position of the Respondent: Dental services are not covered under the Employer Benefit Plan, other than those listed in Article III A. (3) (e), and are specifically excluded by the Plan in Article III A (11) (a) 19. Respondent is not required to provide benefits for the requested dental procedures.
Pertinent Provisions
ARTICLE III BENEFITS
…Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan. In determining questions of reasonableness and necessity, due consideration will be given to the customary practices of physicians in the community where the service is provided. Services which are not reasonable and necessary shall include, but are not limited to the following: procedures which are of unproven value or of questionable current usefulness; procedures which tend to be redundant when performed in combination with other procedures; diagnostic procedures which are unlikely to provide a physician with additional information when they are used repeatedly; procedures which are not ordered by a physician or which are not documented in timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care. The benefits described in this Article are subject to any precertification, prescription drug formulary (PDP) requirements, and other utilization review requirements implemented pursuant to Article IV. Covered services that are medically necessary will continue to be provided, and accordingly, while benefit payments are subject to prescribed limits, this paragraph shall not be construed to detract from plan coverage or eligibility as described in this Article III.
Article III A. (1) (g) of the Employer benefit Plan states:
A. Health Benefits
(1) Inpatient Hospital Benefits
(g) Oral Surgical/Dental Procedures
Benefits are provided for a Beneficiary who is admitted to a hospital for the oral procedures described in subsection (3) (e) provided hospitalization is medically necessary.
Benefits are also provided for a Beneficiary admitted to a hospital for dental procedures only if hospitalization is necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator.
Article III A. (3) (e) of the Employer Benefit Plan states:
A. Health Benefits
(3) Physicians’ Services and Other Primary Care
(e) Oral Surgery
Benefits are not provided for dental services. However, benefits are provided for the following limited oral surgical procedures if performed by a dental surgeon or general surgeon.
Tumors of the jaw (maxilla and mandible) wiring
Frenulectomy when related only to ankyloglossia (tongue tie)
Biopsy of the oral cavity
Fractures of the jaw, including reduction and
Fractures of the facial bones
Temporomandibular Joint Dysfunction, only when medically necessary and related to an oral orthopedic problem.
Dental services required as the result of an accident
Article III A. (11) (a) 19 of the Employer Benefit Plan states:
A. Health Benefits
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
19. Dental Services
Discussion
Article III A of the Employer Benefit Plan expressly excludes the provision of benefits for dental procedures, except for those specific oral surgeries listed in Article III A. (3) (e). The Funds’ Medical Director has reviewed the submitted documentation and has determined that the procedures requested by the Complainant’s physician and dentist are dental procedures not among those oral surgical procedures covered by Article III A. (3) (e), nor are they dental procedures needed as the result of an accident. Although Respondent does not dispute the assertion by Complainant’s physician that Complainant’s underlying medical condition may have
contributed to the periodontal and tooth disease for which the extractions are needed, the Funds’ Medical Director has determined that the requested procedures are not treatments for those underlying medical conditions covered under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not responsible for providing health benefits under the Employer Benefit Plan for the Employee’s requested dental procedures.