December 17, 1984
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-511
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 Advisory Opinion concerning coverage of your oral surgery under the terms of your Employer’s Benefit Plan.
According to Article III. A, (3)(e) of the Employer Plan, benefits are not provided for dental services. However, benefits are provided for the following limited oral surgical procedures, if performed by a dental surgeon or general surgeon:
o Tumors of the jaw (maxilla and mandible)
o Fractures of the jaw, including reduction and wiring
o Fractures of the facial bones
o Frenulectomy when related only to ankyloglossia (tongue tie)
o Temporomandibular Joint Dysfunction, only when medically
necessary and related to an oral orthopedic problem
o Biopsy of lesions of the oral cavity
Under Article III.A.(1)(g), hospital benefits are provided in connection with dental procedures only if the hospitalization is necessary due to a pre-existing medical condition.
In addition, 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. Examples would be: (1) extraction of teeth during emergency treatment of extensive facial damage resulting from an auto accident; (2) the extraction of teeth during treatment of cancers of the head and mouth; and (3) the insertion of a mandibular bone staple to repair a fractured jaw.
A Funds’ medical consultant has reviewed the medical evidence submitted and advised us that your oral surgery is not one of the procedures listed in Article III. A. (3)(e), and that according to the information provided, you do not have a pre-existing medical condition which would satisfy the requirements of Article III. A. (1)(g), and that the surgery you underwent cannot be considered as part of the treatment of an otherwise covered medical condition.
Because the mandibular bone graft, osteotomy, vestibuloplasty, stomoplasty and skin grafting you underwent are not included in the oral surgical procedures mentioned above, and are not part of a treatment for an otherwise covered benefit, they are not covered under the Employer’s Plan. Therefore, your Employer is not responsible for payment of the charges resulting from physician and dentist services related to your oral surgery in this instance. Because your hospitalization was not due to a pre-existing medical condition, your Employer is not responsible for the provision of hospital benefits, including anesthesia services.
Harrison Combs, Chairman
Joseph P. Brennan, Trustee
William Miller, Trustee
Paul R. Dean, Trustee