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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-630 – December 12, 1988
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 temporomandibular joint syndrome treatment under the terms of the Employer Benefit Plan.
Background Facts
A dentist has determined that the Employee’s daughter has a displaced temporomandibular joint disc on the right side with myalgia and myositis (muscle pain). The dentist contends that the condition is orthopedic in nature and not orthodontic, stating that it primarily relates to the jaws and the temporomandibular joints. He Is treating the Employee’s daughter with a mandibular orthopedic repositioning appliance.
The Employer’s standard procedure for reviewing temporomandibular joint syndrome claims includes having a dentist consultant review study models and x-rays of the patient. The physician’s office notified the Employer’s insurance carrier that no x-rays were taken nor study models made of the Employee’s daughter’s mouth. The Employer’s position is that without the documentation to establish the medical necessity of the TMJ treatment, it cannot provide health benefits for the Employee’s daughter’s treatment.
Dispute
Is the Employer responsible for payment of benefits for the Employee’s daughter’s temporomandibular joint syndrome treatment?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of benefits for the Employee’s daughter’s temporomandibular joint syndrome treatment.
Position of the Employer: The Employer is not responsible for payment of benefits for the Employee’s daughter’s temporomandibular joint syndrome treatment because there is inadequate documentation to establish the medical necessity of the treatment provided in this case.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states:
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan.
Article III. A. (3)(e) of the Employer Benefit Plan states:
(e) 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
Fractures 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
Discussion
The Introduction to Article III of the Employer Benefit Plan states that covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care. The Introduction further states that the fact that a procedure or level of care is prescribed by a physician does not necessarily mean that it is medically reasonable or necessary or that it is covered under the Plan. Article III. A. (3)(e) of the Plan stipulates that oral surgical treatment for temporomandibular joint dysfunction is a covered benefit only when it is medically necessary and related to an oral orthopedic problem.
Although the Employer has requested documentation (study models and x-rays) to determine the medical necessity of the Employee’s daughter’s temporomandibular joint syndrome treatment, the documentation has not been provided. A Funds’ physician consultant has reviewed this file and advised that the diagnosis of temporomandibular joint dysfunction has not been established by the documentation presented in this case. He further stated that the information given does not provide adequate justification of the need for a corrective external orthopedic appliance for the Employee’s daughter. Therefore, because the medical necessity of the Employee’s daughter’s temporomandibular joint syndrome treatment has not been established, the Employer’s denial of benefits is justified.
Opinion of the Trustees
The Employer is not responsible for payment of benefits for the Employee’s daughter’s temporomandibular joint syndrome treatment as its medical necessity has not been established.