Opinion of Trustees
Resolution of Dispute
Case No. 88-287
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-287 – September 26, 1990
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 anesthesia services and hospitalization related to the performance of dental procedures under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s three-year-old son was referred by the family’s dentist to a pediatric dentist for treatment of sixteen severely infected abscessed teeth. The pediatric dentist has stated that due to the child’s age, the severity of his oral infection and his lack of ability to cooperate in an office setting, it was necessary for the child’s medical safety to perform the dental treatment under general anesthesia in the outpatient facility of a hospital. The Employee requested prior approval from the Employer for the outpatient hospital facility and anesthesia services charges associated with the dental treatment. The Employer notified the Employee and the dentist before the scheduled procedure that prior approval had not been granted for the hospital facility or anesthesia services charges. The dental treatment (fillings and crown work) was performed under general anesthesia in the outpatient hospital facility on February 7, 1990 with no complications.
The Employer paid the dentist for his services up to the scheduled amount under the Dental Plan. The Employer denied payment under the Employer Benefit Plan for the anesthesia services and the outpatient hospital expenses related to the dental procedures.
Dispute
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Is the Employer required to provide benefits under the Employer Benefit Plan for the anesthesia and outpatient hospital charges associated with the Employee’s son’s dental treatment?
Positions of the Parties
Position of the Employee: The Employer is required to provide health benefits under the Employer Benefit Plan for the anesthesia and hospital charges associated with the Employee’s son’s dental treatment because it was medically necessary for the treatment to be performed in an outpatient surgical center under general anesthesia due to the severity of the infection and the Employee’s son’s acute situational stress syndrome, which constitute preexisting medical conditions.
Position of the Employer: The Employer is not required to provide health benefits under the Employer Benefit Plan for the anesthesia and outpatient hospital charges because hospitalization for the dental procedures was not necessary due to a preexisting medical condition and because prior approval was not given by the Plan Administrator.
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:
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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. (1)(g) of the Employer Benefit Plan states that benefits are provided for hospitalization for oral surgical and dental procedures for (1) beneficiaries admitted for the oral surgical procedures described in Article III. A. (3)(e) of the Plan, if hospitalization is medically necessary, and (2) beneficiaries admitted for dental procedures if hospitalization is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator. In addition to the specific, listed oral surgical procedures, Article III. A. (3)(e) of the Plan provides benefits for dental services required as the direct result of an accident.
The Employee’s son received restorative dental services, including fillings and crown work, as a hospital outpatient. A Funds’ medical consultant has reviewed this file and advised that the dental work performed in this case was not required as the result of an accident and is not one of the limited oral surgical procedures listed in Article III. A. (3)(e). Accordingly, the hospital charge is not covered under the first section of Article III. A. (1)(g) as cited above.
Benefits are otherwise provided under Article III. A. (1)(g) if hospitalization for dental procedures is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator. The Employee sought prior approval from the Plan Administrator and was denied on the grounds that hospitalization for the Employee’s son’s dental procedures was not necessary due to a preexisting medical condition. The dentist in this case has not indicated that the Employee’s son had an underlying medical condition which influenced his decision to use general anesthesia in a hospital setting. There is no indication that the Employee’s son had any medical problems, other than carious teeth, at the time of the hospital admission. The Funds’ medical consultant has advised that there is no evidence of a preexisting medical condition which necessitated hospitalization and the use of general anesthesia for the dental services performed on the Employee’s son. Therefore, benefits are not provided for the hospital charge.
Q&A 81-16 (copy enclosed herein) states that physician services, including anesthesia services, provided in connection with a hospitalization for a non-covered dental procedure may be covered if (1) the hospitalization is medically necessary due to a preexisting medical condition or (2) the services are provided for treatment of a medical condition for which benefits are otherwise provided. As discussed above, the hospitalization of the Employee’s son was not necessitated by a preexisting medical condition. In addition, a Funds’ medical consultant found
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no evidence that the services provided in this case were related to the treatment of any otherwise covered medical condition. The treatment received by the Employee’s son was dental work for his multiple abscessed teeth. Accordingly, benefits are not provided for the anesthesia charge.
Opinion of the Trustees
The Employer is not required to provide benefits under the Employer Benefit Plan for the anesthesia and outpatient hospital charges resulting from the Employee’s son’s dental treatment on February 7, 1990.