February 24, 1986
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-672
Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 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 your son’s oral surgery under the terms of the Employer 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 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 or if the hospitalization is for one of the covered oral surgical procedures listed in Article III.A. (3) (e).
In addition, according to Q&A #81-15, (enclosed herein), certain dental and oral surgical procedures are covered under the Employer Plan 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.
Q&A #81-16, (enclosed herein) provides that physician services including anesthesia services, rendered in a hospital in connection with a non covered dental procedure are covered only when they are part of the treatment of a medical condition for which benefits would otherwise be provided.
A Funds’ consultant has reviewed the medical evidence submitted and is of the opinion that your son’s oral surgery is not one of the procedures listed in Article III. A. (3) (e), that according to the information provided, your son does not have a pre-existing medical condition which would satisfy the requirements of Article III. A. (1) (g), and that the surgery he underwent cannot be considered part of the treatment of an otherwise covered medical condition.
Because the mandibular and maxillary osteotomy and osteoectomy 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 Plan.
Therefore, your Employer is not responsible for payment of the charges resulting from physician and dentist services related to your son’s oral surgery. In addition, because your son’s hospitalization was not due to a pre-existing medical condition, your Employer is not responsible for the provision of hospital benefits, including anesthesia services.
Joseph P. Connors, Sr., Chairman
Paul R. Dean, Trustee
William B. Jordan, Trustee
Donald E. Pierce, Jr., Trustee