Opinion of Trustees
Resolution of Dispute
Case No. 88-255
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 Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, 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’s physician states that for several years he has been treating her for frequent headaches. He states that her severe malocclusion with misalignment of her upper and lower jaw causes her to have muscle fatigue and temporomandibular joint pain leading to headaches.
The Employee’s spouse was evaluated by an oral surgeon who has recommended a maxillary and mandibular osteotomy to realign her upper and lower jaw. The oral surgeon states that her condition is very likely congenital in nature. He states that it is not a dental or cosmetic problem, but a medical condition that involves the facial bones, muscles, ligaments and cartilage of the jaw structure. The oral surgeon states that failure to correct the misalignment of the Employee’s spouse’s facial bone structure will likely lead to continued pain in the temporomandibular joints, ear pain and headaches with continuing degenerative changes within the right and left temporomandibular joints. The oral surgeon also states that the Employee’s spouse may eventually require arthroscopic surgery of the temporomandibular joints; however, that is not being recommended at this time. The oral surgeon requested prior approval for the surgery and inpatient hospitalization.
The Employer has denied a request for prior approval for the Employee’s spouse’s proposed oral surgery.
Dispute
Employee
Employer
88-255 – June 19, 1990
Opinion of Trustees Resolution of Dispute Case No. 88-255
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Is the Employer required to provide health benefits for the Employee’s spouse’s proposed oral surgery?
Positions of the Parties
Position of the Employee: The Employer is required to provide health benefits coverage for the Employee’s spouse’s proposed oral surgery because it is necessary to correct a birth defect. The Employer is required to provide health benefits coverage for the related hospitalization because of the length and intensity of the procedure.
Position of the Employer: The Employer is not required to provide health benefits coverage for the Employee’s spouse’s proposed oral surgery because it is not one of the covered oral surgical procedures under Article III. A. (3)(e), and because it is not part of the treatment of an illness or injury which is otherwise a covered benefit under the Plan. The Employer has not found any medical documentation that the proposed procedures are intended to correct a TMJ dysfunction. The Employer is not required to provide health benefits coverage 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
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(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
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 in this case and has advised that he finds no medical documentation of dysfunction of the patient’s temporomandibular joints. According to the consultant, the proposed oral surgical procedures, a maxillary osteotomy and sagittal split mandibular osteotomy, are not among the limited oral surgical procedures covered under Article III. A. (3)(e) of the Employer Benefit Plan.
According to Q&A 81-15 (copy enclosed herein), charges for dental and oral surgical procedures may also be 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 that is otherwise a covered benefit. The medical consultant has stated that he finds no medical documentation of symptoms or of a specific illness or medical condition related to her temporomandibular joints in the records reviewed. The medical consultant therefore advises that there is no medical evidence that would suggest that the proposed surgery is medically necessary as part of the treatment of an illness or injury that is otherwise covered under the Employer Benefit Plan.
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. The medical consultant has advised that there is no evidence of a preexisting medical condition that would necessitate hospitalization of the Employee’s spouse.
Since the Employee’s spouse’s proposed oral surgery is not one of the covered oral surgical procedures listed in Article III. A. (3)(e) nor part of the treatment for an illness or injury that is otherwise a covered benefit, as discussed in Q&A 81-15, the proposed surgery is not covered
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under the Employer Benefit Plan. 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 required to provide health benefits coverage for the Employee’s spouse’s proposed oral surgery and hospitalization.