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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 88-340 – November 29, 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 health benefits coverage for anesthesia services and hospitalization in connection with dental procedures under the terms of the Employer Benefit Plan.

Background Facts

An oral surgeon recommended that the Employee’s spouse be hospitalized for the removal of an impacted third molar. According to the oral surgeon, hospitalization was medically necessary because the procedure is more difficult on an older patient and because the proximity of the tooth to the mandibular nerve required that the patient be totally immobilized, which can only be accomplished in a controlled hospital environment under general anesthesia. The Employer denied the Employee’s request for prior approval for the hospital and anesthesia charges associated with the dental procedure.

Following a pre-operative physical examination, the Employee’s spouse’s impacted tooth was removed in a hospital on February 23, 1990. In a letter to the Employer’s insurance carrier dated May 30, 1990, the physician who did the pre-operative physical stated that the Employee’s spouse had intra-operative problems that necessitated the anesthesia. The Employer has denied payment under the Employer Benefit Plan for the anesthesia and hospital charges related to the extraction of the Employee’s spouse s impacted tooth.

Dispute

Is the Employer required to provide benefits under the Employer Benefit Plan for the anesthesia and hospital charges associated with the extraction of the Employee’s spouse’s impacted tooth?

Positions of the Parties

Position of the Employee: The Employer is required to provide health benefits under the Employer Benefit Plan for the anesthesia and hospital charges associated with the tooth extraction because it was medically necessary for the procedure to be performed in a hospital setting under general anesthesia due to the patient’s age and the close proximity of the tooth to the mandibular nerve which required that she be totally immobilized.

Position of the Employer: The Employer is not required to provide benefits under the Employer Benefit Plan for the anesthesia and hospital charges associated with the Employee’s spouse’s dental procedure because the removal of an impacted third molar is not among the limited types of oral surgery covered under the Plan, it was not performed as part of the treatment for a medical condition that is otherwise covered under the Plan, and there is no evidence that hospitalization for the procedure was necessary due to a preexisting medical condition.

Pertinent Provisions

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

Under Article III. A. (1)(g) of the Employer Benefit Plan, hospital benefits are 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.

In this case, the Employee’s spouse was hospitalized for’ the removal of an impacted third molar. The oral surgeon has not indicated that the Employee’s spouse had an underlying medical condition that influenced his decision to use general anesthesia in a hospital setting. The patient’s age and the proximity of the impacted tooth to the mandibular nerve may have made the dental procedure more complicated or difficult, but neither of those factors constitutes a pre-existing medical condition that required the tooth extraction to be performed in a hospital setting. Therefore, benefits are not provided for the hospital charge.

Q&A 81-16 (copy enclosed herein) states that physician services, including anesthesia services provided in connection with a hospitalization for a non-covered dental procedure, may be covered if (1) the hospitalization is medically necessary due to a pre-existing medical condition or (2) the services are provided for treatment of a medical condition for which benefits are otherwise provided. As discussed above, there is no indication that the Employee’s spouse’s hospitalization was necessitated by a pre-existing medical condition. There is also no indication that the dental procedure was related to the treatment of any otherwise covered medical condition. Accordingly, benefits are not provided for the anesthesia charges.

Opinion of the Trustees

The Employer is not required to provide benefits under the Employer Benefit Plan for the anesthesia and hospital charges resulting from the Employee’s spouse’s oral surgery on February 23, 1990.