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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-399 – November 20, 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 benefits for oral surgery under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse has been diagnosed as having severe atrophy of the mandible (lower jaw). Her oral surgeon is proposing corrective surgery in two stages. The first stage is placement of five osseo-integrated reconstructive implants, also known as dental implants. After a six-month healing period, a prosthesis or replacement teeth would be attached to the implants for the second stage.
The record shows the Employee’s spouse has a history of facial, mouth and jaw problems, following an automobile accident in September 1979, in which she sustained a head injury, a fracture of the second cervical vertebra, and multiple facial fractures. Since this accident, she has been treated for temporomandibular joint (TMJ) dysfunction. Such treatment has included reconstructive surgery of the right TMJ In September 1986, followed by left TMJ surgery in November 1986 and September 1987.
The Employer has denied benefits for the dental implant surgery.
Dispute
Is the Employer required to provide benefits for the Employee’s spouse’s dental implant surgery?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s spouse’s dental implant surgery because it is required as the direct result of an accident.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s spouse’s dental implant surgery because (1) the car accident in question occurred in 1979, when there was no provision in the Employer Benefit Plan for dental coverage because of an accident; (2) there is no evidence that the atrophy of the lower jaw is the result of the accident; and (3) the dental Implant surgery is not among the Plan-covered oral surgical procedures. Additionally, the Employee’s spouse’s lower-jaw teeth were extracted in 1981, two years after the accident, and the atrophy of the lower jaw is probably the result of natural degeneration of the bone following the extraction of teeth.
Pertinent Provisions
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
Article III. A. (3)(e) of the Employer Benefit Plan states that benefits are not provided for dental services, except those required as the direct result of an accident. Article III. A. (3)(e) also specifies the limited oral surgical procedures for which benefits are provided. Among those procedures is treatment for TMJ dysfunction only when medically necessary and related to an oral orthopedic problem.
A Funds’ medical consultant has reviewed this case, including records of the Employee’s spouse’s medical treatment for injuries sustained in the automobile accident In 1979, records of TMJ surgeries performed on the right and left temporomandibular joints in 1986 and 1987, and letters from her oral surgeon pertaining to the proposed dental implant surgery. The consultant states that he finds no medical documentation that the proposed dental implant surgery is medically necessary to treat a continuing TMJ dysfunction. The consultant has advised that the surgery is intended to correct the patient’s mandibular atrophy, not to specifically reorient the temporomandibular joint. The consultant further states that he finds no evidence that the proposed dental implant surgery is required as a direct result of the Employee’s spouse’s automobile accident. The consultant concurs with the Employer’s dental professional staff that the patient’s mandibular atrophy is a result of having her lower teeth extracted in December 1981. The Funds’ consultant concluded that, for these reasons, the proposed oral surgery is not among the limited oral surgical procedures covered under Article III. A. (3)(e) of the Employer Benefit Plan.
According to Q&A 81-15 (copy enclosed herein), dental and oral surgical procedures other than those listed in Article III. A. (3)(e) may also be covered under the Employer Benefit Plan, but only when performed in a hospital as part of the treatment for an illness or injury which Is otherwise a covered benefit. The Employee’s spouse’s oral surgeon has recommended surgical reconstruction of the mandible with endosseous implants for the purpose of attaching replacement teeth to the gums or bones of her mouth. The Funds’ medical consultant has advised that there is no medical documentation that would suggest that the implant surgery is medically necessary as part of the treatment of an illness or injury that is otherwise covered under the Employer Benefit Plan.
Inasmuch as the Employee’s spouse’s dental implant surgery is not required as the direct result of an accident, is not medically necessary for the treatment of TMJ dysfunction, and is not medically necessary as part of the treatment of an illness or injury that is otherwise covered under the Employer Benefit Plan, the Employer is not required to provide benefits for the Employee’s spouse’s dental implant surgery.
Opinion of the Trustees
The Employer is not required to provide health benefits for the Employee’s spouse’s proposed dental-implant surgery.