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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-319 – November 14, 1990
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 benefits for treatment of temporomandibular joint dysfunction for an Employee’s daughter under the terms of the Employer Benefit Plan.
Background Facts
In November 1986, a dentist who specializes in the treatment of temporomandibular joint (TMJ) disorder diagnosed the Employee’s daughter as having TMJ problems caused by a mandibular shift to the left resulting in displacement of the right and left condyle and a slight rotation of the lower jaw. The dentist states that the Employee’s daughter had presented with a history of the following complaints: some popping and clicking of the joints, some right ear hearing loss, allergies/sinus troubles, difficulty in swallowing, neuromusclar spasms, some chest pains and high blood pressure. The dentist states that the treatment initiated in November 1986 was a combination splint/orthopedic appliance that was medically necessary to reposition the mandible and eliminate most, if not all, of the Employee’s daughter’s complaints.
The Employer states that in December 1986 it Initiated its standard procedure for reviewing disputed TMJ snydrome claims. In February 1987, the Employer’s dental consultant reviewed the x-rays and notes provided by the oral surgeon. The consultant determined that the treatment provided was orthodontic in nature and not medically necessary to correct the Employee’s daughter’s complaints. Thus, the Employer denied benefits under the Employer Benefit Plan for the Employee’s daughter’s treatment.
Dispute
Is the Employer required to provide benefits for the Employee’s daughter’s treatment for temporomandibular joint problems?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s daughter’s treatment for temporomandibular joint problems because such treatment is covered under the Employer Benefit Plan.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s daughter’s treatment for temporomandibular joint problems because there is inadequate medical documentation to establish its medical necessity and the treatment provided was orthodontic in nature.
Pertinent Provisions
The Introduction to Article III 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:
(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 ankylogossia (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. 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 the Plan. Article III. A. (3)(e) of the Employer Benefit Plan, as discussed in Q&A 81-88 (copy enclosed herein), provides benefits for the use of corrective external orthopedic appliances as a treatment for temporomandibular joint dsyfunction only when such treatment is medically necessary and related to an oral orthopedic problem. The Employer’s insurance carrier’s dental consultant has reviewed documentation provided by the oral surgeon involving the Employer’s daughter’s treatment and determined that the treatment was orthodontic in nature and not medically necessary to correct the complaints reported by the oral surgeon.
A Fund’s medical consultant has reviewed the information collected in this case and has stated that the documentation provided does not establish the presence of a temporomandibular joint problem that would require treatment with an external orthopedic appliance. The consultant has advised that the Employee’s daughter’s treatment with an external orthopedic appliance was orthodontic in nature. Inasmuch as the medical necessity of the Employee’s daughter’s TMJ syndrome treatment has not been established, the Employer’s denial of benefits is justified.
Opinion of the Trustees
The Employer is not required to provide benefits for the Employee’s daughter’s treatment for temporomandibular joint problems, as its medical necessity has not been established.