July 27, 1982
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-56
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 coverage of your spouse’s oral surgery under the terms of your Employer’s Benefit Plan.
According to Article III. A. (3) (e) of the Employer Plan, 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 lesions of the oral cavity
In addition, according to Q&A #81-15, attached hereto, certain dental and oral surgical procedures are covered under the Employer’s Plan only when performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit. Examples would be: (1) extraction of teeth during emergency treatment of extensive facial damage resulting from an auto accident; (2) the extraction of teeth during treatment of cancers of the head and mouth; and (3) the insertion of a mandibular bone staple to repair a fractured jaw.
Because the osteotomy, vestibuloplasty and skin grafting performed on your spouse are not included in the oral surgical procedures mentioned above, and are not part of a treatment for an otherwise covered benefit, they are not covered under the Employer’s Plan.
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee