June 28, 1983
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 313
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 your Request for Advisory Opinion concerning the level of health benefit coverage for treatment of temporomandibular joint dysfunction.
According to the information received, the Employee’s spouse received an orthopedic repositioning appliance from her oral surgeon and, during a three-month period, visited his office for adjustments to the appliance. The Employer has denied benefits for the services because it feels they are dental in nature. The Employer informed us that if these services are determined to be covered, it will waive the requirement of prior approval.
Under 1978 Contract Question and Answer #115, attached hereto, treatment of temporomandibular joint dysfunction is not a covered benefit unless the treatment involves the use of a corrective external orthopedic appliance or corrective surgery to specifically reorient the temporomandibular joint and prior approval is obtained from the Plan Administrator. The Trustees have been advised that the treatment rendered did, in fact, involve the use of a corrective external orthopedic appliance as required in Q&A #115, the Employer is responsible for the provision of benefit coverage for the treatment of the Employee’s spouse’s temporomandibular joint dysfunction.
Sincerely,
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee
Attachment
Date: April 16, 1980
Control Number: 115
Index Reference Number: III A 3
Subject: Oral Orthopedics
References: Amended 1950 & 1974 Benefit Plans and Trusts,
Article III, Sect. A (3)(m), and (e) and A(10)(a) 19
Question: Is treatment for Temporomandibular Joint Dysfunction a covered benefit?
Answer: No, except when treatment involves:
1. the use of a corrective external orthopedic appliance; or
2. corrective surgery to specifically reorient the temporomandibular joint.
If either treatment is to be rendered by an oral surgeon, prior approval must be obtained from the Trustees.
Benefits are not provided for treatment for T.M.J. which involves the insertion of dentures.