July 25, 1983 (Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees Resolution of Dispute
Case No. 81-280
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 oral surgery under the Employer’s Plan.
Article III. A. (3)(e) of your Employer’s Plan specifically excludes benefits for dental services. Under Q&A #81-15, the extraction of teeth is not a covered benefit unless performed in a hospital as part of a treatment for an illness or injury which is otherwise a covered benefit. Because the extraction of your teeth was not part of a treatment for an illness or injury which is otherwise a covered benefit, your Employer is not responsible for payment of charges for your extractions.
Q&A #81-16, attached hereto, provides that physician services, including anesthesia services that are performed in connection with dental procedures, are a covered benefit only when they are for the treatment of a medical condition for which benefits would otherwise be covered. Because you did not have an otherwise covered medical condition, benefits are not provided for anesthesia services performed in connection with your dental procedures.
Sincerely,
Harrison Combs, Chairman
John J. O’Connell, Trustee
Attachment
Paul R. Dean, Trustee
Subject: References:
Question:
Control Number: 81-16
Hospitalization and Professional Services for Dental Procedures
Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Sections A (1) (a), A (3) (d) and (e) and A (11) 19
- Is oral surgery a covered benefit?
- Are dental services a covered benefit?
- Are hospitalization charges for semi-private room and board related to a non- covered dental procedure covered under the Plan?
- 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?
- Are benefits provided for physician services (enumerated in Article III, Section A (3)) in connection with a hospitalization for a non-covered dental procedure?
Answer:
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
2. No.
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.
3. & 4.
5. No, except for the treatment of a medical condition for which benefits would otherwise be provided.