February 13, 1984
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-259
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 an Advisory Opinion concerning coverage of your dependent’s oral surgery under the Employer’s Benefit Plan.
Article III. A. (3)(e) of your Employer’s Plan specifically excludes benefits for dental services. Under Article III. A. (1)(g) of the Employer’s Benefit Plan, benefits are provided for hospitalization 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 dependent had no known preexisting medical condition and prior approval was not obtained from your Plan Administrator, your Employer is not responsible for payment of charges for your dependent’s hospitalization for 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 your dependent did not have an otherwise covered medical condition, benefits are not provided for anesthesia services performed in connection with his 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.