______________________________________________________________________________
OPINION OF TRUSTEES
______________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-118 – February 24, 1986
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee;, William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, jr., Trustee.
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 the facts and circumstances of this dispute concerning the provision of health benefits for the treatment of temporomandibular joint dysfunction under the terms of the Employer Benefit Plan.
Background Facts
A dentist diagnosed the spouse of the Employee as having a complete displacement of the left temporomandibular joint. The dentist devised a splint to reposition the lower jaw and stabilize the associated muscles and inserted it in the patient’s oral cavity. Subsequently, a mandibular orthopedic repositioning appliance was inserted in the oral cavity by an oral maxillofacial prosthodontist, for the purpose of correcting the displacement. The Employer’s health insurance carrier made partial payments ($87.50 of the $725.00 billed by the dentist and $112.50 of the $870.00 billed by the prosthodontist) and denied the remainder of the bills for these services. There is no Explanation of Benefits (EOB) available for the services billed by the dentist, and no reason for the denial appears on the photocopy of the EOB for the services billed by the prosthodontist which the Employee provided the Trustees.
Question or Dispute
Is the Employer responsible for payment of benefits for the specific services rendered the Employee’s spouse for treatment of temporomandibular joint dysfunction?
Position of the Parties
Position of the Employee: The Employer is responsible for payment of benefits for the expenses incurred in treatment of the Employee’s spouse for temporomandibular joint dysfunction.
Position of the Employer: The Employer has failed to present any information or state its position to the Funds despite repeated requests for information.
Pertinent Provisions
Article III. A. (3) (e) of the Employer Benefit Plan states:
Oral Surgery
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:
Tumors of the jaw (maxilla and mandible)
Fractures of the jaw, including reduction and wiring Fracture of the facial bones
Frenulectomy when related only to ankyloglossia (tongue tie)
Temporomandibular joint Dysfunction, only when medically necessary and related to an oral orthopedic problem
Biopsy of the oral cavity
Dental services required as the direct result of an accident
Q&A #81-88 states:
Subject: Oral Orthopedics
References: Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Section A (3)(e) and (m), and A (11) (a) 19
Question:
Are benefits provided for treatment of Temporomandibular joint Dysfunction?
Answer:
No, except when treatment involves:
1. the use of corrective external orthopedic appliances; or
2. corrective surgery to specifically reorient the temporomandibular joint.
If either treatment is to be rendered by an oral surgeon, prior approval must be obtained from the Plan Administrator.
Benefits are not provided for treatment for T.M.J. which involves the insertion of dentures.
Discussion
Under Article III. A. (3) (e) of the Employer Benefit Plan, benefits are provided for oral surgical procedures for temporomandibular joint dysfunction when medically necessary and related to an oral orthopedic problem. The diagnosis in this case was complete displacement of the temporomandibular joint, and the treatment involved placement of a splint to reposition the lower jaw and stabilize the associated muscles and then an orthopedic appliance to reposition the bones which comprise the temporomandibular joint. This treatment satisfies the requirements of Article III. A. (3) (e) in that it was medically necessary and appropriate for the treatment of an oral orthopedic problem.
Q&A #81-88 states that benefits are provided for treatment of temporomandibular joint dysfunction when that treatment involves the use of corrective external orthopedic appliances. The splint and appliance used to treat the Employee’s spouse were inserted into the oral cavity without surgical intervention and therefore were “external” appliances. The treatment received by the Employee’s spouse therefore did involve the use of corrective external orthopedic appliances as required in Q&A #81-88.
It is not clear, based on the available documentation, which services were paid or denied by the Employer’s health insurance carrier. The Employer has failed to present any information or state its position despite repeated requests for information. Based on the limited information which is available, it appears that benefits were paid for the dentist’s examination and the prosthodontist’s examination and x-rays, and that no benefits were paid for the splint inserted by the dentist or the orthopedic appliance inserted by the prosthodontist. However, it is clear that all of the specific services billed are covered under Article III. A. (3) (e) and Q&A #81-88. There is no indication that prior approval was sought or obtained, nor is there any indication that the denial was based on failure to obtain prior approval.
Opinion of the Trustees
The Employer is responsible for providing benefits for all of the specific services rendered the Employee’s spouse for the treatment of temporomandibular joint dysfunction.