January 31, 1984
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-388
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 son’s oral surgery under the Employer’s Benefit Plan.
Article Ill. 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 pre-existing medical condition, and when prior approval has been received from the Plan Administrator,
According to Q&A #81-15, attached hereto, certain dental and oral surgical procedures are covered under the Employer’s Plan only when performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit.
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.
Although Dr. Wallace suspects that your son may have early degenerative joint disease of the temporomandibular joints and has indicated that, if his skeletal facial deformity were not corrected, the suspected degenerative joint disease would probably become more symptomatic, there is no evidence that your son has temporomandibular joint disease nor is there any indication that he has been treated for such a problem in the past.
A Funds’ medical consultant has reviewed the medical evidence submitted and advised us that your son’s oral surgery is not one of the procedures listed in Article III. A. (3)(e), and that according to the information provided, he does 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. Wallace cannot be considered as part of the treatment of an otherwise covered medical condition. Therefore, your Employer is not responsible for payment for physician services, including anesthesia services, or for hospitalization charges related to your son’s oral surgery in this instance.
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee