December 21, 1983
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-383
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 coverage of physician services and hospitalization for your oral surgery under the Employer’s Benefit Plan.
Article III. A. (3)(e) of your Employer’s Benefit Plan specifically excludes benefits for dental services, except for the following limited oral surgical procedures, when 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
Article III. A. (1)(g) of your Employer’s Benefit Plan provides benefits for medically necessary hospitalization when the admission is for an oral surgical procedure listed in Article III. A. (3)(e). Benefits are also provided when hospitalization for a dental procedure is necessary due to a beneficiary’s preexisting medical condition, and when prior approval has been received from the Plan Administrator.
Q&A #81-16, a copy of which is enclosed, 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.
A Funds medical consultant has advised us that your oral surgery is not one of the procedures listed in Article III. A. (3)(e), that you do not have a pre-existing medical condition which would satisfy the requirements of Article III. A. (1)(g), and that the surgery performed by Dr. Ellis cannot be considered as part of the treatment of an otherwise covered medical condition. In addition, prior approval of this hospitalization was not obtained from your Plan Administrator. Therefore, your Employer is not responsible for payment for physician services, including anesthesia services, or for hospitalization charges related to your oral surgery in this instance.
Sincerely,
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Harrison Combs, Chairman
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John J. O’Connell, Trustee
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Paul R. Dean, Trustee