August 29, 1983
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-233
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 Resolution of Dispute concerning the level of health benefit coverage for a corrective external orthopedic appliance.
Your dependent’s condition has been diagnosed as orthopedic and neuromuscular in nature, characterized by skeletal malalignment of the mandible to the skull and concomitant spasms of the masticatory muscles and the cervical muscles attached to this bone. The patient has received a musculoskeletal appliance (splint). Your Employer has paid for the splint but has denied coverage for the treatment surrounding it.
Under 1981 Contract Question and Answer #81-88, 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. The Trustees have been advised that the treatment rendered did, in fact, involve the use of a corrective external orthopedic appliance for the treatment of temporomandibular joint dysfunction as required under Q&A #81-88 and is, therefore, a covered benefit.
Sincerely,
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee
Control Number: 81-88
Subject: Oral Orthopedics
References: Amended 1950 & 1975 Benefit Plans & Trusts,
Article III, Section A (3) (e) and (m), and A (11) (a) 19
Question:
Are benefits provided for treatment of Temporomandibular Joint Dysfunction?
Answer:
No, except when treatment involves:
1. the use of corrective external orthopedic appliances; or
2. corrective surgery to specifically reorient the temporomandibular joint.
If either treatment is to be rendered by an oral surgery, prior approval must be obtained from the Plan Administrator.
Benefits are not provided for treatment for T.M.J. which involves the insertion of dentures.