May 20, 1985
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-599
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 benefits coverage under the Employer Benefit Plan for the treatment of your dependent’s problem which you have described as temporomandibular joint (TMJ) dysfunction.
The Employer Benefit Plan, in Article III. A. 11 (a) 19, specifically excludes coverage of dental services. Benefits for the treatment of TMJ dysfunction are covered only when the treatment involves corrective surgery or the use of corrective external orthopedic appliances (Q&A 81-88, attached thereto).
According to a claim for dental expense benefits signed by Dr. Thomas in. Jarrett on October 1, 1984, your daughter, Lisa, was described as having an extremely severe problem which will require her to be in full bands for at least 20-24 months. A diagnosis for this problem has not been furnished. According to the same form, the date of your daughter’s first visit to Dr. Jarrett was October 26, 1983, and the appliances billed for by Dr. Jarrett were put in place on January 24, 1984. In a letter dated September 25, 1984, Dr. Jarrett states that some of your daughter’s chief complaints were severe headaches, locking in the right temporomandibular joint and a deviated opening to her right side. He indicates in the same letter that he began treating Lisa with some orthodontic appliances and a bite splint in order to resolve these problems. Orthodontics, according to Dorland’s Medical Dictionary, is a branch of dentistry which deals with the development, prevention and correction of irregularities of the teeth and malocclusion, and with associated facial abnormalities. Orthodontic treatment is not a covered benefit under your Employer’s Plan.
An external appliance used for treatment of TMJ syndrome is distinctly different from, and should not be confused with, braces or bands. The use of such a device, if necessary for the treatment of TMJ dysfunction, is a covered orthopedic benefit under the terms of the Employer Benefit Plan.
In addition to describing the disputed services your daughter requires, you have alleged that you contacted your Employer’s insurance company for prior approval of these services, and that such approval was granted. There is no information available to support your contention that a request for prior approval was made or that the Employer granted prior approval for coverage of the disputed services.
Since the full bands that your daughter requires are considered orthodontic appliances used to correct a malocclusion, your Employer is not responsible for providing benefits for this service. Your Employer is responsible for coverage of the bite splint used to specifically reorient your daughter’s TMJ.
Sincerely,
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Joseph P. Connors, Sr., Chairman
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Paul R. Dean, Trustee
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William B. Jordan, Trustee
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William Miller, Trustee
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Donald E. Pierce, Jr., Trustee