Opinion of the Trustees ROD Case No. 17
December 14, 1979
(Opinion issued in letter form; name and address deleted)
Re: Resolution of Dispute Case No. 17
Pursuant to Article IX of the UMWA 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the U.S. Department of Labor, the Trustees have received a question concerning coverage for outpatient hospitalization charges associated with dental procedures under the Employer’s benefit plan. Their opinion is issued in Question and Answer form, as follows:
Hospitalization and Professional Services for Dental Procedures
1) Is oral surgery a covered benefit?
2) Are dental services a covered benefit?
3) Are hospitalization charges for semi-private room, and board
related to dental procedures covered under the Plan?
4) Are the medically necessary services sometimes associated with
hospitalization enumerated in Article III, Section A, (b)(a) and physician services enumerated in Article III, Section A (3) covered benefits when provided in connection with a hospital admission for dental procedures?
1) No, except for the following limited procedures when (1) performed by a dental or general surgeon and (2) only with the prior approval of the Trustees:
– tumors of the jaw
– fractures of the jaw, including reduction and wiring – fractures of the facial bones
– frenulectomy, when related to ankyloglossia
3) Yes, when (1) medically necessary and (2) prior authorization has been obtained from the Plan Administrator
4) No, except for the treatment of medical conditions.
Opinion of the Trustees
ROD Case No. 17
According to the provisions of Q&A #88 part (2), dental services are not a covered benefit and therefore the charges for the surgical extraction of teeth are not covered. Part (4) of the Q&A states that ancillary services associated with the hospitalization charges for dental procedures are not covered, unless administered as treatment for medical conditions. The attending physician has stated that although the use of general anesthesia requiring hospitalization was the method of choice, it was not dictated by any general medical problems. Therefore, the hospitalization charges associated with the extraction of teeth are not covered.
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee