February 22, 1983
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-139
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 under the Employer’s Benefit Plan for your oral surgery and for the anesthesiologist’s charges.
Article III. A. (3)(e) of your Employer’s Benefit Plan specifically excludes benefits for dental services, with the exception of the following limited oral surgical procedures if performed by a dental surgeon or oral 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
Under Article III. A. (1)(g) of the Employer’s Benefit Plan, as amended June 7, 1981, benefits are provided for hospitalization, if medically necessary, for the limited oral surgical procedures listed in Article III. A. (3)(e), and for dental procedures only if the hospitalization is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator. A Fund’s medical consultant has determined that your oral surgery was not one of the procedures listed in Article III. A. (3)(e), and that you had no preexisting medical condition. Therefore, your Employer is not responsible for payment of charges for your oral surgery.
Q&A #81-16, attached hereto, provides that physician services, including anesthesia services, are a covered benefit only when they are for the treatment of a medical condition for which benefits would otherwise be provided. Because you did not have an otherwise covered medical condition, benefits are not provided for anesthesia services performed in connection with your dental procedures.
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee
Control Number: 81-16
Subject: Hospitalization and Professional Services for Dental Procedures
References: Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Sections A (1) (a), A (3) (d) and (e) and A (11) 19
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), (2) and (3) 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?
1. Yes, if such surgery receives the prior approval of the Plan Administrator and is performed in a hospital and hospitalization is medically necessary, benefits are provided for oral surgery treating
o tumors of the jaw
o fractures of the jaw, including reduction and wiring
o fractures of the facial bones
o frenulectomy when related only to ankyloglossia
o temporomandibular Joint Dysfunction, only when medically necessary and related to an oral orthopedic problem
o biopsy of lesions of the oral cavity
3. & 4. No, except when, 1) hospitalization is medically necessary because of pre-existing medical condition, and 2) prior authorization has been obtained from the Plan Administrator.
5. No, except for the treatment of a medical condition for which benefits would otherwise be provided.