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OPINION OF TRUSTEES
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In Re
Complainants: Employee
Respondent: Employer
ROD Case No: 84-462 – January 11, 1988
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 for temporomandibular joint syndrome treatment under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s dental surgeon states that the Employee has temporomandibular joint dysfunction that is manifested by bilateral popping, clicking and pain in the region of the left temporomandibular joint. The condition creates soreness in the muscles of mastication and difficulty in biting and chewing food. The Employee also suffers from headaches, lightheadedness, neckaches, ringing in his ears and numbness/tingling in his fingertips. The Employee’s dental surgeon characterizes the Employee’s problem as orthopedic in nature and inserted a mandibular repositioning orthopedic appliance on May 28, 1986 to allow the spastic muscles to relax and reduce pain and clicking in the joint. The Employee’s dental surgeon maintains that the treatment is neither realigning the teeth (orthodontic treatment) nor correcting a malocclusion but repositioning the mandible.
The Employer denied health benefits coverage for the insertion of the mandibular repositioning orthopedic appliance after the Employer’s insurance carrier submitted x-rays and study models of the Employee’s mouth to a dental consultant. The dental consultant determined that the services performed were orthodontic in nature and therefore not covered under the Employer Benefit Plan or the Dental Plan.
Dispute
Is the Employer responsible for the payment of benefits for the Employee’s temporomandibular joint syndrome treatment?
Positions of the Parties
Position of the Employee: The Employer is responsible for the payment of benefits for the Employee’s temporomandibular joint syndrome treatment.
Position of the Employer: The Employer is not responsible for the payment of benefits for the Employee’s temporomandibular joint syndrome treatment because the treatment rendered was orthodontic in nature and therefore not covered under the Employer Benefit or Dental Plans.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states in 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 the direct result of an accident
Discussion
The Introduction to Article III of the Employer Benefit Plan states that covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury. 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 the Plan. Article III. A. (3)(e) of the Employer Benefit Plan, as interpreted by the Trustees in Q&A 81-88 (copy enclosed herein), provides benefits for the use of an external orthopedic appliance as a treatment for temporomandibular joint dysfunction, only when such treatment is medically necessary and related to an oral orthopedic problem.
The Employer’s insurance carrier’s dental consultant has reviewed x-rays and study models of the Employee’s mouth and determined that the services rendered were orthodontic in nature. The Funds’ physician consultant has reviewed this file and advised that there is inadequate documentation of temporomandibular joint dysfunction to warrant treatment with an external orthopedic appliance. Therefore, the medical necessity of the Employee’s temporomandibular joint syndrome treatment has not been established, and the Employer’s denial of benefits is justified.
Opinion of the Trustees
The Employer is not responsible for payment of benefits for the Employee’s temporomandibular joint syndrome treatment as its medical necessity has not been established.
Control Number: 81-88
Subject: Oral Orthopedics
References: Amended 1950 & 1975 Benefit Plans & Trusts,
Article III, Section A (3) (e) and (m), and A (11) (a) 19
Question:
Are benefits provided for treatment of Temporomandibular Joint Dysfunction?
Answer:
No, except when treatment involves:
1. the use of corrective external orthopedic appliances; or
2. corrective surgery to specifically reorient the temporomandibular joint.
If either treatment is to be rendered by an oral surgery, prior approval must be obtained from the Plan Administrator.
Benefits are not provided for treatment for T.M.J. which involves the insertion of dentures.