Opinion of Trustees
Resolution of Dispute
Case No. 84-286
Page 1 ______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-286 – August 12, 1987
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.
Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits for oral surgery under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse was seen by an oral surgeon December 12, 1984 for complaints of popping and clicking of both temporomandibular joints, pain in both temporomandibular joints and difficulty in biting and chewing her food. The oral surgeon diagnosed the Employee’s spouse as having a deep overjet overbite with a mandibular retrognathia. The mandibular retrognathia is a skeletal deformity which in his opinion caused the Employee’s spouse pain, discomfort and degeneration of the temporomandibular joint. The treatment plan consisted of a course of orthodontic therapy to be followed by oral surgery to reposition the lower jaw for the purpose of alleviating her problem and complaints relative to the temporomandibular joints. The oral surgical procedures, bilateral sagittal split osteotomies and Le Fort I osteotomy, were performed approximately one year later, December 20, 1985.
The Employer’s insurance carrier denied payment of medical benefits for the osteotomies, but did pay dental benefits. The insurance carrier paid medical benefits for the associated hospitalization, but the Employer states that the payment was made in error and is seeking recoupment from the Employee.
Dispute
Is the Employer responsible for the provision of health benefits coverage for the Employee’s spouse’s oral surgery?
Positions of the Parties
Opinion of Trustees Resolution of Dispute Case No. 84-286
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Position of the Employee: The Employer is responsible for the provision of health benefits coverage for the Employee’s spouse’s oral surgery because the surgery to correct TMJ dysfunction was medically necessary and related to an oral orthopedic problem.
Position of the Employer: The Employer is not responsible for providing medical benefits or the Employee’s spouse’s oral surgery and associated hospitalization because osteoplasty to correct mandibular retrognathia is not one of the covered oral surgical procedures under Article III. A. (3)(e).
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states:
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. Covered services that are medically necessary will continue to be provided, and accordingly 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: (g) Oral Surgical/Dental Procedures
Benefits are provided for a Beneficiary who is admitted to a hospital for the oral surgical procedures described in paragraph (3)(e) provided hospitalization is medically necessary.
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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: (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)
Fractures of the jaw, including reduction and wiring
Fractures of the facial bones
Frenulectomy when related only to ankyloglossia (tongue tie) Temporomandibular Joint Dysfunction, only when medically necessary
and related to an oral orthopedic problem Biopsy of the oral cavity
Dental services required as the direct result of an accident Discussion
Under Article III. A. (3)(e) of the Employer Benefit Plan, benefits are provided for oral surgery to treat Temporomandibular Joint Dysfunction when medically necessary and related to an oral orthopedic problem. The symptoms exhibited by the Employee’s spouse were popping and clicking of the joints, pain and difficulty biting and chewing food. Neither the Employee nor the oral surgeon has presented any evidence to suggest these symptoms were of sufficient severity to warrant such radical intervention as surgical restructuring of the jaw. Furthermore, it does not appear that any more conservative therapies were attempted prior to the initiation of the orthodontics/oral surgery treatment plan.
A Funds’ medical consultant has reviewed the medical evidence submitted and advised that insufficient medical justification has been provided to establish that the Employee’s spouse’s oral surgery was medically necessary. Therefore, the professional charge for the surgery is not a covered benefit under Article III. A. (3)(e) of the Employer Benefit Plan.
Article III. A. (1)(g) of the Employer Benefit Plan provides hospitalization benefits for the oral surgical procedures described in Article III. A. (3)(e) provided hospitalization is medically necessary. Since the oral surgical procedure was not medically necessary and, therefore not covered under Article III. A. (3)(e), the hospitalization associated with the procedure is also not a covered benefit.
Opinion of the Trustees
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The Employer is not responsible for providing health benefits coverage for the Employee’s spouse’s oral surgery or hospitalization for treatment of her skeletal deformity.