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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 93-076 – December 1, 1997
Trustees: Thomas F. Connors, Michael H. Holland, Donald E. Pierce, Jr. and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for the treatment of temporomandibular joint dysfunction under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse has been diagnosed as having temporomandibular joint dysfunction (TMJ). Her treatment, which began in January 1992, consisted of periodic office visits for therapy and incorporation of an orthotic splint/orthopedic appliance. The Employer provided benefits for treatments as well as the appliance. The Employer ended benefits for services after those provided on May 24, 1996, stating that “there was no concrete medical reason given for continued treatment and only vague assurances that treatment may soon end.” The Employee states that benefits should continue because the services had been pre-approved.
Dispute
Is the Employer required to continue benefits for the Employee’s spouse’s TMJ treatment beyond May 24, 1996?
Positions of the Parties
Position of the Employee: The Employer is required to continue benefits for the TMJ treatment because it was pre-approved.
Position of the Employer: The Employer is not required to continue benefits for the TMJ treatment because there is no indication of medical necessity.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states, in pertinent part:
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan. . . .
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.
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 a direct result of an accident
Discussion
The Introduction to Article III of the Employer Benefit Plan limits covered services to those that are medically necessary for the diagnosis and treatment of an illness or injury. A physician may prescribe services or treatment, but the medical necessity for such care must be established before benefits may be provided under the Plan. Article III. A. (3) (e) provides benefits for limited oral conditions.
In this case, a Funds’ medical consultant has reviewed the documentation provided and has concluded that there is nothing to support the medical necessity for treatment beyond May 1996 and any further treatment would not be covered by the Employer Benefit Plan’s requirements of medical necessity.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for the Employee’s spouse’s continued TMJ treatment beyond May 24, 1996.