Opinion of Trustees
Resolution of Dispute
Case No. 88-109
Page 1 _____________________________________________________________________________

OPINION OF TRUSTEES _____________________________________________________________________________

In Re

Complainant: Respondent: ROD Case No:

Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, 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 coverage for oral surgery under the terms of the Employer Benefit Plan.

Background Facts

An oral surgeon has diagnosed the Employee’s spouse as having mandibular retrognathia (a receding jaw) and a displaced temporomandibular joint disc on the left side that causes her pain. Initially she was treated with an anterior repositioning splint that, according to the oral surgeon, relieved her temporomandibular joint discomfort. After the Employee’s spouse’s temporomandibular joint symptoms were alleviated, she underwent orthodontic therapy. The oral surgeon states that upon completion of her orthodontic therapy, she will need repositioning of her lower jaw to correct the skeletal deformity of her mandible.

The oral surgeon proposes to perform a bilateral sagittal split osteotomy to reposition the jaw and thereby realign the temporomandibular joint disc. The oral surgeon recommends correction of the skeletal deformity in lieu of operating on the left temporomandibular joint at the present time. He indicated that if the proposed surgery does not correct the problem, he will operate on the left temporomandibular joint itself. The oral surgeon requested prior approval for the corrective oral surgery and for the related hospitalization. The Employer denied health benefits coverage for the Employee’s spouse’s proposed oral surgery.

Dispute

Is the Employer required to provide health benefits coverage for the Employee’s spouse’s proposed oral surgery?

Positions of the Parties

Employee
Employer
88-109 – July 24, 1989

Opinion of Trustees Resolution of Dispute Case No. 88-109
Page 2

Position of the Employee: The Employer is required to provide health benefits coverage for the Employee’s spouse s proposed oral surgery because it is necessary to correct a temporomandibular joint disorder.
Position of the Employer: The Employer is not required to provide health benefits coverage for the proposed oral surgery because the procedure is not a covered benefit under the Employer Benefit Plan.

Pertinent Provisions Article III. A. (l)(g) of the Employer Benefit Plan states:

(1) Inpatient Hospital Benefits
(g) Oral Surgical/Dental Procedures

Benefits are provided for a Beneficiary who is admitted to a hospital for the oral surgical procedures described in paragraph (3)(e) provided hospitalization is medically necessary.

Benefits are also provided for a Beneficiary admitted to a hospital for dental procedures only if hospitalization is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator.

Article III. A. (3)(e) of the Employer Benefit Plan states: (3) Physicians’ Services and Other Primary Care

(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

Opinion of Trustees Resolution of Dispute Case No. 88-109
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Article III. A. (3)(e) of the Employer Benefit Plan specifies the limited oral surgical procedures for which benefits are provided. Among these procedures is treatment for temporomandibular joint dysfunction under certain circumstances. Q&A 81-88 (copy enclosed herein) further indicates that the only two instances in which benefits are provided for treatment of temporomandibular joint dysfunction are when treatment involves (1) the use of corrective external appliances or (2) corrective surgery to specifically reorient the temporomandibular joint.

A Funds’ medical consultant has reviewed the information submitted in this case, including two letters from the Employee’s spouse’s oral surgeon, a second opinion, x-rays and study models. The consultant advised that the medical documentation provided does not establish that the proposed surgery is medically necessary to treat temporomandibular joint dysfunction. The consultant is of the opinion that the proposed treatment is primarily orthodontic in nature in that it is intended to correct an overbite and associated facial abnormalities, not to specifically treat temporomandibular joint dysfunction. Therefore, the surgical correction of the Employee’s spouse’s receding jaw is not one of the limited oral surgical procedures covered under Article III. A. (3)(e) of the Plan.

According to Q&A 81-15 (copy enclosed herein), charges for dental and oral surgical procedures may also be covered under the Employer Benefit Plan if the procedure is performed in a hospital as part of the treatment for an illness or injury that is otherwise a covered benefit. The medical consultant has advised that no evidence has been submitted to establish that the proposed surgery is medically necessary to treat an otherwise covered medical condition.

Article III. A. (l)(g) of the Employer Benefit Plan provides benefits for medically necessary hospitalization when the admission is for an oral surgical procedure listed in Article III. A. (3)(e). Inpatient hospital benefits are also provided when hospitalization for a dental procedure is necessary due to a beneficiary’s preexisting medical condition and prior approval has been received from the Plan Administrator. The consultant has advised that there is no evidence of a preexisting medical condition that would necessitate hospitalization for the proposed surgery.

Since the Employee’s spouse s proposed oral surgery is neither a) one of the covered oral surgical procedures listed in Article III. A. (3)(e) nor b) part of the treatment for an illness or injury that is otherwise a covered benefit, as discussed in Q&A 81-15, the proposed surgery is not covered under the Employer Benefit Plan. Furthermore, because the proposed surgery is not one of the covered oral surgical procedures listed in Article III. A. (3)(e) and there is no evidence of a preexisting medical condition, the hospitalization associated with the proposed procedure does not meet the requirements for coverage under Article III. A. (1)(g).

Opinion of the Trustees

The Employer is not required to provide health benefits coverage for the Employee’s spouse’s proposed oral surgery.