OPINION OF TRUSTEES
ROD Case No: 88-608 – February 16, 1995
Trustees: Thomas F. Connors, Michael H. Holland, Marty D. Hudson and
Robert T. Wallace.
The Trustees have reviewed the facts and circumstances of this dispute concerning benefits for oral surgery under the terms of the Employer Benefit Plan.
On March 19, 1992 the Employee’s oral surgeon wrote to the Employer’s claims administrator seeking pre-authorization of surgical benefits for the Employee’s proposed oral surgery. The oral surgeon’s letter indicates that the Employee was suffering from a restricted range of motion in both temporal and cervical regions, impingement of lower teeth on palatal mucosa and interference with mastication (chewing) because of skeletal mandibular hypoplasia and collapse of posterior occlusion. The Employee’s chief complaints were of progressive severe pain and inability to masticate.
The oral surgeon’s treatment plan included two Osseointegrated Branemark implants to the Mandible, Bilateral Sagittal Split Osteotomies, and a Horizontal Mandibular Osteotomy. The total fee for the procedures, including $1,000 for an assistant surgeon, was $8,000. The Employer’s claims administrator determined that the services were dental in nature and referred the charges to the dental department for a pre-determination of benefits. On May 11, 1992 the dental department of the Employer’s claims administrator informed the Employee that $750 of the $8,000 would be eligible under the Employer’s dental plan. The pre-determination of benefits stated that it was not a guarantee of benefits.
On June 11, 1992 the Employee filed a Resolution of Dispute stating that he felt that his Employer should pay for the proposed surgery to relieve his pain and suffering, and because this type of surgery had been paid for in the past and should be paid for in this instance due to medical reasons.
On July 7, 1992 the Employee underwent the surgical procedures recommended by the oral surgeon. Subsequent to the surgery, the Employer’s claims administrator received the bills for services in connection with the surgical procedures. The entire hospital bill was paid in full under the medical plan, minus a prompt payment discount for which the Employee would not be responsible. Of the surgeon’s bill, $450 was paid under the Employer’s dental plan. The Employee appealed the surgical fee determination to the Employee’s
claims administrator who, after re-reviewing the medical records, on August 28, 1992 made a final determination that the surgery was dental in nature and that the original benefit determination was correct.
Are the surgical charges incurred on July 7, 1992 eligible for benefits under the medical portion of the Employer Benefit Plan?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s oral surgery on July 7, 1992 under the medical portion of the Plan since the surgery was being done for medical reasons and had been paid for in the past.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s oral surgery under the medical portion of the Employer Benefit Plan since the type of surgery is not among the eligible surgical procedures listed in Article III.A.(3)(e) of the Employer Benefit Plan. Additionally, the medical documentation does not establish that the Employee’s surgery was medically necessary as part of the treatment of an illness or injury that is otherwise covered under the Plan, in accordance with Q&A 81-15. There was no evidence of a pre-existing medical condition that would necessitate the hospitalization as provided for under Article III.A.(1)(g), and Article III.A.(7)(a) 1. specifically excludes benefits for dental prosthetic devices.
The Introduction to Article III states in pertinent part:
ARTICLE III BENEFITS
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. (1) (g) states:
(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.
Article III.A. (3) (e) 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
Temporomandibular Joint Dysfunction, only when medically necessary and related to an oral orthopedic problem.
Biopsy of the oral cavity
Dental services as a direct result of an accident
Article III.A. (11) (a) 19. states:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise outlined in the Plan, benefits are also not provided for the following:
19. Dental services.
The Introduction to Article III provides benefits for services which are reasonable and necessary for the diagnosis and treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for under 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) provides benefits for limited oral surgical procedures. A Funds’ medical consultant has reviewed the medical documentation submitted and has determined that the surgeries performed are not among the limited oral surgical procedures covered by Article III.A.(3)(e). The medical consultant notes that the fourth diagnosis listed by the patient’s attending physician was temporomandibular and cervical myofascial pain dysfunction syndrome. In order to obtain coverage under the Plan’s provisions for temporomandibular
joint dysfunction the patient’s primary physician would need to submit medical documentation of chronic difficulties the patient is having specific to a diagnosed temporomandibular joint dysfunction, e.g. intractable pain and troubles with mastication that are causing other documented gastrointestinal problems. In the consultant’s opinion, the letter from the oral surgeon does not meet the requirements for medical documentation.
Article III.A.(1)(g) provides hospital benefits for oral surgical/dental procedures only when hospitalization is necessary due to a pre-existing medical condition and when prior approval is received from the Plan Administrator. The Funds’ medical consultant advises that, in his opinion, the surgery was not medically necessary as part of a treatment for an illness or injury otherwise covered under the Plan. And the consultant notes that although the patient had a grade I/IV mitral valve murmur, it has not been treated and is not documented as being significant, and, in the opinion of the consultant, would not require the patient to be hospitalized under the provisions of Article III.A.(1)(g) of the Employer Benefit Plan.
Additionally, Article III.A.(11)(a) 19. specifically excludes benefits for dental services.
Therefore, the Trustees conclude that the oral surgery performed on the Employee on July 7, 1992 does not qualify for benefits under the limited provisions of Article III.A.(3)(e), and the hospitalization would not be eligible under the provisions of Article III.A.(1)(g) of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide benefits under the medical portion of the Plan for the Employee’s oral surgery on July 7, 1992.