August 31, 1984
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-471
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 anesthesia services provided in connection with inpatient dental surgery under the Employer’s Benefit Plan.
Article III. A. (1) (g) of the Employer’s Benefit Plan provides benefits for hospitalization for a dental procedure when the admission is medically necessary due to a beneficiary’s pre-existing 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.
In accordance with Article III A. (1) (g) of the Employer’s Benefit Plan, the Employee’s daughter’s congenital heart disease qualifies as a pre-existing medical condition which, according to her physician, necessitated the hospitalization for her dental surgery. Recognizing this fact, the Employer authorized payment of the charges resulting from the hospitalization. However, the anesthesia charges related to this surgery have been denied. You contend that these charges should be covered by the Employer since you believe that the anesthesia was provided as a treatment of the child’s pre-existing congenital heart disease.
Based on the information you provided, it appears that the dental surgery the Employee’s daughter underwent was not related to the treatment of her pre-existing medical condition, even though this condition required that the surgery be performed in a hospital setting. The anesthesia at issue in this dispute was obviously administered as a means to accomplish the dental surgery and not as treatment of the child’s congenital heart disease. In addition, from a clinical standpoint the anesthesia would have no therapeutic effect on the child’s condition, in this instance.
Because the disputed anesthesia services cannot be considered as part of the treatment of an otherwise covered medical condition, the requirements for coverage of physician services provided in connection with a hospitalization for a non-covered dental procedure, as established in Q&A 81-16, have not been satisfied.
The Employer, therefore, is not responsible for payment of the anesthesia services provided to the Employee’s daughter during her medically necessary hospitalization for dental surgery.
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee