Opinion of Trustees
Resolution of Dispute
Case No. 84-476
Page 1 ______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-476 – October 29, 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 coverage for oral surgery under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s son has an asymmetrical mandible with an open bite on the right side. He cannot properly close his jaws and has pain in the temporomandibular joint area when attempting to chew. The Employee’s son’s dental surgeon characterizes this condition as a skeletal problem, not a dental one. The dental surgeon is requesting prior approval for corrective oral surgery, (i.e., a saggital split osteotomy) and for the related hospitalization.
The Employer contends that the proposed oral surgery to correct the Employee’s son’s skeletal defect is not one of the covered procedures listed in Article III. A. (3)(e) of the Employer Benefit Plan. It also maintains that the child’s proposed surgery is not part of the treatment for an otherwise covered benefit nor does the child have a preexisting medical condition which would satisfy the requirements of Article III. A. (1)(g)
Dispute
Is the Employer responsible for the provision of health benefits coverage for the dental surgeon’s fee and for the hospitalization charges for the Employee’s son’s oral surgery?
Positions of the Parties
Position of the Employee: The Employer is responsible for the provision of health benefits coverage for the Employee’s son’s proposed oral surgery because it is one of the covered oral surgical procedures under Article III. A. (3)(e) of the Employer Benefit Plan.
Opinion of Trustees Resolution of Dispute Case No. 84-476
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Position of the Employer: The Employer is not responsible for the provision of health benefits coverage for the Employee’s son’s oral surgery because it is not one of the covered oral surgical procedures under Article III. A. (3)(e), and there is no evidence that the surgery is part of the treatment for an otherwise covered benefit. The Employer is not responsible for the provision of health benefits for the related hospitalization charges because a preexisting medical condition has not been documented as required under Article III A. (1)(g) of the Employer Benefit Plan.
Pertinent Provisions Article III. A. (1)(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 preexisting medical condition and prior approval is received from the Plan Administrator.
Article III. A. (3)(e) of the Employer Benefit Plan states: (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)
Fractures of the jaw, including reduction and wiring
Fracture 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. 84-476
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Discussion
Article III. A. (3)(e) of the Employer Benefit Plan stipulates that oral surgical treatment for temporomandibular joint dysfunction is a covered benefit only when it is medically necessary and related to an oral orthopedic problem. Q&A 81-88 (copy enclosed herein) states that corrective surgery to specifically reorient the temporomandibular joint is a covered treatment for TMJ dysfunction. A Funds’ medical consultant has reviewed the information submitted by the dental surgeon and has advised that the proposed surgery is intended to correct an orthodontic problem (open bite) and not to specifically reorient the temporomandibular joint.
In addition, according to Q&A 81-15 (copy enclosed herein), charges for dental and oral surgical procedures are covered under the Employer Benefit Plan only when the procedure is performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit. No evidence has been submitted to establish that this surgery is medically necessary to treat an otherwise covered illness or injury.
Article III. A. (I)(g) of the Employer Benefit Plan provides benefits for medically necessary hospitalization when the admission is for an oral surgical procedure listed in Article III. A. (3)(e). Inpatient hospital benefits are also provided when hospitalization for a dental procedure is necessary due to a beneficiary’s preexisting medical condition, and when prior approval has been received from the Plan Administrator. The Funds’ medical consultant has advised that there is no evidence of a preexisting medical condition.
Since the patient’s proposed oral surgery is not a) one of the covered oral surgical procedures listed in Article III. A. (3)(e) or b) part of the treatment for an illness or injury which is otherwise a covered benefit, the professional services fees are not covered. Because the surgery is not one of the covered oral surgical procedures listed in Article III. A. (3)(e) and there is no evidence of a preexisting medical condition, the patient’s hospitalization does not meet the requirements for coverage under Article III. A. (1)(g)
Opinion of the Trustees
The Employer is not responsible for the provision of health benefits for the Employee’s son’s proposed oral surgery and hospitalization.