January 25, 1983
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-123
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 oral surgery (removal of a mandibular tori and multiple infected teeth) and period of hospitalization under the terms of your Employer’s Benefit Plan.
Article III. E (3)(e) of the Employer’s Benefit Plan specifically excludes dental services from coverage. 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 to ankyloglossia (tongue tie) Temporomandibular Joint Dysfunction, only when medically necessary and related to an oral orthopedic problem
Biopsy of lesions of the oral capita
Under Article III. A (1)(g) of the Employer’s Benefit Plan, benefits are provided for hospitalization, when medically necessary, for the oral surgical procedures described in Article III. A (3)(e). In addition, hospital benefits are provided for a beneficiary admitted to a hospital for dental procedures only if the hospitalization is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator. Because your oral surgery is not included in the oral surgical procedures mentioned above, and because hospitalization was not necessitated due to a preexisting medical condition and prior approval was not obtained from your Plan Administrator, your Employer is not responsible for payment of charges for your oral surgery and hospitalization.
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee