OPINION OF TRUSTEES
ROD Case No: 88-541 – July 15, 1992
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Elliot A. Segal, 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 oral surgery under the terms of the Employer Benefit Plan.
In September 1990, an oral surgeon diagnosed the Employee’s spouse as having lesions of her right uvula and left external oblique ramus ridge (areas of the right tonsil and left upper jaw). Noting his concern that the lesions might be cancerous, the surgeon proposed an early operation. For unrelated reasons, the spouse decided to have the rest of her upper teeth removed at the same time. On September 21, 1990 the Employee’s spouse underwent the oral surgery, which included an excisional biopsy of the orpharynx, a frenulectomy and extractions of eight upper teeth. The procedures were done in the local hospital under a general anesthetic on an outpatient basis. The surgeon did not seek prior approval, citing a need to do the procedures as soon as possible, and noting that approval often took six to eight weeks.
The Employer provided benefits for all allowable surgical charges, but denied benefits for the hospital charges, the anesthesia and the pathologist’s charges. The Employer stated these procedures could have been done with equal efficacy in the oral surgeon’s office.
Is the Employer required to provide benefits for the hospital, anesthesia and pathology charges incurred in connection with the Employee’s spouse’s oral surgery performed on September 21, 1990?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the hospital, anesthesia and pathology charges in connection with the Employee’s spouse’s oral surgery on September 21, 1990 because the surgeries were considered eligible expenses and the use of the hospital was medically necessary.
Position of the Employer: The Employer is not required to provide benefits for the hospital, anesthesia, and pathology charges incurred by the Employee’s spouse in connection with her oral surgery on September 21, 1990, because the hospitalization and related charges were not medically necessary and could have been provided with equal efficacy at a lower level of care.
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 preexisting medical condition and prior approval is received from the Plan Administrator.
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
Under Article III. A. (1)(g) of the Plan, benefits are provided for hospitalization for dental procedures only if necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator. As an example, pre-existing conditions such as heart disease, hypertension, diabetes or chronic obstructive pulmonary disease (COPD) could put a beneficiary at significant risk of developing complications that could result in further injury, damage or loss if the dental services (covered or non-covered) were performed in a less controlled environment. The Funds’ medical consultant has advised that there is no documentation of a pre-existing medical condition that would have necessitated hospitalization for these dental procedures. Further, the consultant notes that there is no medical documentation of the need to use the hospital facilities on an outpatient basis for the covered oral surgery. Therefore, the requirements for hospitalization under Article III. A. (1)(g) were not met.
The pathological examination of the biopsy specimens is an integral component of the surgical procedure. Thus, the pathology charge would be eligible for benefits, regardless of the setting for the surgery. Similarly, anesthesia would be necessary for the surgeon to secure the biopsy specimens, and also eligible for benefits.
Opinion of the Trustees
The Employer is required to provide benefits under the Employer Benefit Plan for the pathology charges and anesthesia charges related to the biopsy of the oropharynx; however, the Employer is not required to provide benefits for the hospital charges incurred by the Employee’s spouse on September 21, 1990.