RE: Opinion of Trustees
Resolution of Dispute
Case #108, September 29, 1980
Pursuant to Article IX of the United Mine Workers of America 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 coverage for dental services and associated charges for hospitalization and anesthesia. Their opinion is issued in Question and Answer form as follows:
Subject: Hospitalization and Professional Services for Dental Procedures
References: Amended 1950 & 1974 Benefit Plans and Trusts, Article III, Section A (1)(a) and A (3)(d) and (e)
Questions: 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 a non-covered dental procedure covered under the Plan?
4. Are benefits provided for the medically necessary services (enumerated in Article III, Section A (1) and (2)) in connection with hospitalization for a non-covered dental procedure?
5. Are benefits provided for physician services (enumerated in Article III, Section A(3)) in connection with a hospitalization for a non-covered dental procedure?
Answers: 1. Yes, for these limited procedures:
o tumors of the jaw
o fractures of the jaw, including reduction and wiring
o fractures of the facial bones
o frenulectomy, when related to ankyloglossia
3 & 4. No, except when 1) hospitalization is medically necessary because of an under in medical condition and 2) prior authorization has been obtained from the Trustees.
5. No, except for the treatment of a medical condition for which benefits would otherwise be provided.
Any charges incurred for an oral surgical procedure other than the four limited procedures listed in the Plan are excluded from coverage. Secondly, charges for hospitalization and anesthesiology related to the oral surgery are covered only if medically necessary because of an underlying medical condition and have been approved by the Plan Administrator. Charges associated with oral surgical procedures are otherwise excluded from coverage.