Opinion of Trustees
Resolution of Dispute
Case No. 84-404
Page 1 ______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
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 inpatient hospitalization for dental and oral surgical procedures under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s medical physician evaluated the Employee for pain in the right jaw, diagnosed extensive periodontal disease and referred him to an oral surgeon for treatment. The oral surgeon, who determined that the Employee had four impacted teeth and twenty-seven non- restorable abscessed teeth, performed a full-mouth extraction of the abscessed teeth, surgically removed the four impacted teeth and surgically altered the shape of the bony cavities in the jaw bone (four-quadrant alveoloplasty). Due to the extent of the procedures, the potential for blood loss and the Employee’s severe anxiety and low pain threshold, the procedures were performed under general anesthesia in an inpatient hospital setting.
The Employer denied payment for the inpatient hospitalization charges associated with the procedures.
Dispute
Is the Employer responsible for payment of the inpatient charges incurred when the Employee was admitted to the hospital for the full-mouth extraction of teeth?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of the inpatient charges incurred when the Employee was admitted to the hospital for the full-mouth extraction of teeth because verbal approval was obtained from the Plan Administrator.
Employee
Employer
84-404 – July 17, 1987
Opinion of Trustees Resolution of Dispute Case No. 84-404
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Position of the Employee: The Employer is not responsible for payment of the inpatient charges incurred when the Employee was admitted to the hospital for the full-mouth extraction of teeth as the procedures performed are not among the oral surgical procedures covered by the Plan, the Employee did not have a pre-existing medical condition requiring that the procedures be performed on an inpatient basis and the Employee did not receive prior approval.
Pertinent Provisions Article III A. (I)(g) of the Employer Benefit Plan states:
(1) Inpatient Hospital Benefits
(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.
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.
Q&A 81-82 states:
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
Opinion of Trustees Resolution of Dispute Case No. 84-404
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Subject: Inpatient Hospital and Physician Coverage Associated with the Provisions of Non-Covered Benefits
References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (I) (g) Question:
A beneficiary acquires a condition, the treatment for which is not a covered benefit (e.g., dental treatment or oral surgery). Hospitalization is required for this treatment only because of a pre- existing condition (such as heart disease), the treatment for which is a covered benefit.
- Are benefits provided for the hospitalization costs?
- Are benefits provided for the physician’s fees associated with care for the prior condition?
- In the case of the non-covered service, i.e., dental treatment, are benefits provided for the charges associated with it?
Answer:
- Yes, if prior approval is obtained from the Plan Administrator.
- Yes. Benefits are provided for charges associated only with the prior condition, which is a covered benefit.
- No. (Dental services are not a covered benefit.)
Q&A 81-16 states:
Subject: Hospitalization and Professional Services for Dental Procedures
References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (1) (a), A (3) (d) and (e) and A (11) 19
Question:
- Is oral surgery a covered benefit?
- Are dental services a covered benefit?
- Are hospitalization charges for semi-private room and board related to a non- covered dental procedure covered under the Plan?
Opinion of Trustees Resolution of Dispute Case No. 84-404
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4.
5. Answer:
1.
Are benefits provided for the medically necessary services (enumerated in Article III, Section A (1), (2) and (3) in connection with hospitalization for a non-covered dental procedure?
Are benefits provided for physician services (enumerated in Article III, Section A (3)) in connection with a hospitalization for a non-covered dental procedure?
Yes, if such surgery receives the prior approval of the Plan Administrator and is performed in a hospital and hospitalization is medically necessary, benefits are provided for oral surgery treating
o tumors of the jaw
o fractures of the jaw, including reduction and wiring
o fractures of the facial bones
o frenulectomy, when related to ankyloglossia
o temporomandibular joint dysfunction, only when medically necessary and
related to an oral orthopedic problem. o biopsy of lesions of the oral cavity
No.
No, except when, 1) hospitalization is medically necessary because of pre- existing medical condition, and 2) prior authorization has been obtained from the Plan Administrator.
No, except for the treatment of a medical condition for which benefits would otherwise be provided.
Discussion
2. 3. & 4.
5.
Under Article III A. (1)(g) of the Employer Benefit Plan, benefits are provided for inpatient charges incurred when a beneficiary is admitted to the hospital for a dental procedure if hospitalization is necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator. The oral surgeon stated that the Employee was admitted to the hospital due to the extent of the procedure to be performed, the potential for blood loss and the Employee’s severe anxiety and low pain threshold. There is no evidence that the Employee suffered from a pre-existing medical condition that required the tooth extraction to be performed in a hospital setting.
The Employee stated that prior to the surgery he informed the Plan Administrator that he would be absent from work for one week due to hospitalization for the tooth extraction. The Plan Administrator instructed the Employee to obtain a statement from his physician providing just cause for the absence.
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The Employee claims that these instructions amounted to verbal approval for the hospitalization and therefore satisfied the prior approval requirements of the Plan. However, the discussion between the Employee and the Plan Administrator pertained to a planned absence for dental work and not to a planned hospitalization. The discussion did not, therefore, constitute prior approval of health benefits coverage for the hospitalization.
Article III A. (1)(g) of the Employer Benefit Plan also provides for medically necessary hospitalization for the oral surgical procedures listed in Article III A. (3)(e). The full-mouth tooth extraction performed on the Employee is not one of these covered oral surgical procedures.
Since the Employee did not have a pre-existing medical condition that required hospitalization for the dental procedure and prior approval was not sought for a hospitalization, and the procedure which occasioned hospitalization was not one of the oral surgical procedures listed in Article III A. (3)(e), the inpatient charge incurred when the beneficiary was admitted to the hospital for the full-mouth tooth extraction is not a covered benefit under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not responsible for payment of the inpatient charges incurred when the Employee was admitted to the hospital for the full-mouth extraction of teeth.