_____________________________________________________________________________
OPINION OF TRUSTEES
_____________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-272 – June 19, 1991
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 for oral surgery and the related hospitalization for an Employee’s daughter under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s daughter was seen by an oral surgeon who has stated that she suffered from severe skeletal deformities which caused temporomandibular joint dysfunction, muscle spasms of the head and neck region, and difficulty in chewing and swallowing. He recommended the following surgical procedures to correct the jaw deformity and to prevent further temporomandibular joint dysfunction: LeFort I inferior and anterior maxillary repositioning osteotomy, mandibular sagittal split ramus advancement osteotomy, mandibular osteotomy of the inferior border – setback osteotomy and extraction of four third molars.
The Employee requested prior approval from the Employer for the proposed oral surgery. The Employer’s insurance carrier notified the Employee and the oral surgeon in a letter dated February 15, 1990 that prior approval was denied because the procedures were not covered under the Employer Benefit Plan. The surgery was performed in a hospital on March 5, 1990. The Employer has maintained its denial of benefits under the Employer Benefit Plan for the Employee’s daughter’s oral surgery and the related hospitalization.
Dispute
Is the Employer required to provide health benefits under the Employer Benefit Plan for the Employee’s daughter’s oral surgery and the related hospitalization?
Positions of the Parties
Position of the Employee: The Employer is required to provide health benefits under the Employer Benefit Plan for the Employee’s daughter’s oral surgery and the related hospitalization because the oral surgeon has determined that the surgery was medically necessary to correct temporomandibular joint dysfunction that was related to the Employee’s daughter’s oral orthopedic problems.
Position of the Employer: The Employer is not required to provide health benefits under the Employer Benefit Plan for the Employee’s daughter’s oral surgery because the surgery performed is not among the covered procedures listed under Article III. A. (3)(e) of the Plan, and it was not part of the treatment for a medical condition which is otherwise covered under the Plan. The Employer is not required to provide benefits for the related hospitalization because the oral surgical procedures are not covered under the Plan and there is no evidence of a preexisting medical condition, as required for coverage under Article III. A. (1)(g) of the Employer Benefit Plan.
Pertinent Provisions
Article III. A. (3)(e) of the Employer Benefit Plan states:
(3) Physician’s 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
Article III. A. (1)(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 pre-existing medical condition and prior approval is received from the Plan Administrator.
Discussion
Article III. A. (3)(e) of the Employer Benefit Plan specifies the limited oral surgical procedures for which benefits are provided. Among those procedures is surgery 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 orthopedic appliances, or (2) corrective surgery to specifically reorient the temporomandibular joint. A Funds’ medical consultant has reviewed the information submitted in this case, including records of the Employee’s daughter’s dental history prior to the surgery and the oral surgeon s report of the operation. The consultant has advised that the medical documentation provided does not establish the existence of a temporomandibular joint dysfunction. The consultant has also advised that the oral surgical procedures performed in this case are not among the limited oral surgical procedures covered by Article III. A. (3)(e), as interpreted in Q&A 81-88, for temporomandibular joint dysfunction. The consultant advised that the Employee’s daughter’s oral surgery was not designed to specifically reorient the temporomandibular joint.
According to Q&A 81-15 (copy enclosed herein), benefits for dental and oral surgical procedures may also be covered under the Employer Benefit Plan only when 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 medical evidence has been submitted to establish that the Employee’s daughter’s oral surgery was medically necessary as part of the treatment of an otherwise covered medical condition.
Article III. A. (1)(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). Benefits are also provided when hospitalization for oral surgery is necessary due to a pre-existing medical condition and prior approval has been received from the Plan Administrator. The Funds’ medical consultant has advised that there is no evidence of a pre-existing medical condition which necessitated hospitalization for the Employee’s daughter’s oral surgery.
Since the Employee’s daughter’s oral surgery is not among the covered oral surgical procedures listed in Article III. A. (3)(e), and was not performed as part of the treatment for an illness or injury that is otherwise a covered benefit, as discussed in Q&A 81-15, the professional fees for the surgery are 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 pre-existing medical condition, the hospitalization associated with the oral surgery 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 for the Employee’s daughter’s oral surgery and the related hospitalization under the terms of the Employer Benefit Plan.