Opinion of Trustees
Resolution of Dispute
Case No. 88-015
Page 1 ______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-015 – January 13, 1989
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 spouse has a history of debilitating headaches. She was referred to an oral surgeon who states that the primary source of her headaches is a congenital malformation of both the maxilla and mandible, with resultant gross discrepancy in jaw alignment. He states that this discrepancy caused significant non-synchronous dysfunction of the muscles of the face and head and chronic muscle spasms. Since this condition may lead to temporomandibular joint problems, the oral surgeon ordered an MRI (magnetic resonance imaging) scan of both temporomandibular joints. The results indicated that both joints were normal. The oral surgeon recommended a mandibular osteotomy to correct the alleged congenital malformation of the jaw and prior approval was requested from the Plan Administrator.
The Employer has denied benefits for the proposed oral surgery, stating that it is not one of the covered oral surgical procedures listed under Article III. A. (3)(e) of the Employer Benefit Plan. The Employer has denied benefits for the related hospitalization, stating that a preexisting medical condition has not been documented as required under Article III. A. (1)(g) of the Plan. The Employer also maintains that the Employee’s spouse’s proposed surgery is not part of the treatment of an otherwise covered illness or injury.
Dispute
Is the Employer responsible for the provision of health benefits coverage for the Employee’s spouse’s proposed oral surgery?
Positions of the Parties
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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 proposed oral surgery because it is medically necessary to relieve her headaches.
Position of the Employer: The Employer is not responsible for the provision of health benefits coverage for the Employee’s spouse’s oral surgery because it is not one of the covered oral surgical procedures listed under article III. A. (3)(e) of the Employer Benefit Plan, and there is no evidence that the surgery is part of the treatment for an otherwise covered illness or injury. 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 a 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)
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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
Article III. A. (3)(e) of the Employer Benefit Plan specifies the limited oral surgical procedures for which benefits are provided. Among those procedures is surgery for temporomandibular joint dysfunction (TMJ), under certain circumstances. A Funds’ medical consultant has reviewed the information submitted by the oral surgeon and has advised that the patient’s proposed mandibular osteotomy is not among the limited oral surgical procedures covered under Article III. A. (3)(e) of the Plan. The consultant further advised that there is no documentation of a temporomandibular joint problem or syndrome.
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. (1)(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. A Funds’ medical consultant has advised that there is no evidence of a preexisting medical condition.
Since the Employee’s spouse’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, as discussed in Q&A 81-15, the professional services fees cannot be covered. Furthermore, because the proposed 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 proposed 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 coverage for the Employee’s spouse’s proposed oral surgery.