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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-426 – 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 treatment of temporomandibular joint dysfunction under the Employer Benefit Plan.
Background Facts
The Employee’s spouse has temporomandibular joint (TMJ) dysfunction, manifested by neck pains or stiffness, earaches, dizziness, difficulty in opening and closing her mouth, clenching or grinding her teeth, pain in her jaw joints and pain or numbness in the muscles of her face. An oral surgeon fitted her with a series of splints to confirm the diagnosis and to position her mandible (lower jaw) correctly in the temporomandibular joint. After two years, the oral surgeon fitted her with a removable orthopedic appliance as a permanent solution.
The Employer has denied payment for the appliance, stating that it is not a covered benefit under either its dental plan or its health benefits plan.
Dispute
Is the Employer required to provide health benefits coverage for the treatment of the Employee’s spouse’s TMJ dysfunction?
Positions of the Parties
Position of the Employee: The Employee ask whether the Employer is required to provide health benefits coverage for the treatment of the Employee’s spouse’s TMJ dysfunction.
Position of the Employer: The Employer is not required to provide health benefits coverage for treatment of the Employee’s spouse’s TMJ dysfunction with a removable orthopedic appliance because Article III. A. (3)(e) of the Employer Benefit Plan provides benefits only for oral surgery to correct TMJ dysfunction. The Employer has also denied benefits for the services in question under its dental plan.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states in part:
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.
Article III. A. (3)(e) of the Plan states:
(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
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 and which are given at the appropriate level of care. Article III. A: (3)(e) of the Plan provides that oral surgical treatment for TMJ dysfunction is a covered benefit only when it is medically necessary and related to an oral orthopedic problem. Q&A 81-88 (copy enclosed herein) further states that benefits are provided for treatment of TMJ dysfunction when treatment involves (1) the use of corrective external appliances or (2) corrective surgery to specifically reorient the temporomandibular joint.
The Employer has denied coverage for the treatment of TMJ dysfunction with a removable orthopedic appliance, stating that only oral surgical treatment for TMJ dysfunction is a covered benefit under the Employer Benefit Plan. However, as noted in ROD 84-496 (copy enclosed herein) the use of a corrective external orthopedic appliance is a more conservative alternative to surgery for treatment of TMJ dysfunction, and it is consistent with the appropriate level of care requirement under the Plan to provide benefits under Article III. A. (3)(e) for the use of such appliances in cases where TMJ dysfunction may be corrected non-surgically.
A Funds’ medical consultant has reviewed this case, including a letter from the spouse’s oral surgeon. The consultant is of the opinion that the external orthopedic appliance is medically necessary to reorient the temporomandibular joint and treat the patient’s TMJ syndrome. Because the Employee’s spouse’s treatment for TMJ was medically necessary and related to an oral orthopedic problem, consistent with Article III. A. (3)(e) of the Plan, the charge for the medically necessary orthopedic appliance is covered under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is required to provide benefits for the treatment of the Employee’s spouse’s TMJ dysfunction.