Opinion of Trustees Resolution of Dispute Case No. 81-529
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January 28, 1985

(Opinion issued in letter form; name and address deleted)

Re: Opinion of Trustees Resolution of Dispute

Case No. 81-529

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 for your wife’s proposed oral surgery under the Employer’s Benefit Plan.

On September 24, 1984 you submitted a request to your Employer to consider coverage of a LeFort I maxillary osteotomy and a mandibular sagittal split osteotomy (bilateral), to be performed on your wife. This request stated that the nature of the problem was congenital rather than cosmetic and that it was necessary to correct a malformation of her jaw and teeth.

The Employer denied this request because the procedures in question are not among the limited oral surgical procedures covered under the Employer’s Benefit Plan. The Employer advised you, however that, were the procedures to be performed at a time that you were eligible for dental coverage, the procedure could be considered for payment subject to the conditions of that plan.

You contend that, as a congenital malformation, the problem should be covered under the Employer’s Benefit Plan as a medical problem and you have asked that the Trustees rule in this dispute.

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

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

Opinion of Trustees Resolution of Dispute Case No. 81-529
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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 other- wise 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.

A Funds’ medical consultant has reviewed the medical evidence submitted and advised us that your wife’s oral surgery is not one of the procedures listed in Article III. A. (3)(e). Furthermore, according to the information provided, she does not have a pre-existing medical condition which would satisfy the requirements of Article III. A. (1)(g). Therefore, the proposed oral surgery cannot be considered as part of the treatment of an otherwise covered medical condition. Because the procedures in question are non-covered oral surgical procedures, whether your wife’s condition may be congenital is not relevant. Consequently, your Employer is not responsible for payment for oral surgery services, including anesthesia services, or for hospitalization charges related to your wife’s oral surgery in this instance.


Harrison Combs, Chairman

Joseph P. Brennan, Trustee

William B. Miller, Trustee

Paul R. Dean, Trustee