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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-728 – March 27, 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 the provision of health benefits coverage for anesthesia charges in connection with an oral surgical procedure under the terms of the Employer Benefit Plan.
Background Facts
On March 11, 1992, the Employee’s daughter underwent the surgical removal of four (4) complete bony impactions of her maxillary and mandibular (upper and lower) right and left third molars (wisdom teeth) under general anesthesia in the outpatient department of a local hospital. The dentist performing the surgery stated that due to the Employee’s daughter’s history of asthma and the extent of the surgical procedure, she presented a potential anesthetic risk as well as an airway management problem. Therefore, the dentist recommended the surgery be done in an outpatient hospital setting with a qualified anesthesiologist in attendance.
The Employer paid the appropriate benefits for the administration of the anesthesia under the Employee’s dental plan, and denied the remaining balance under the major medical portion of the Plan, stating that the service was not an eligible expense under the terms of the Employer Benefit Plan.
Dispute
Is the Employer required to provide benefits for the administration of anesthesia in connection with the surgical removal of the Employee’s daughter’s four (4) impacted wisdom teeth on March 11, 1992 in an outpatient hospital setting?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the administration of anesthesia in connection with the removal of the Employee’s daughter’s impacted wisdom teeth because the oral surgeon stated that it was medically necessary due to the daughter’s asthma which could present a potential anesthesia risk as well as a possible airway management problem.
Position of the Employer: The Employer is not required to provide medical benefits for the anesthesia administration because the service is specifically excluded under the terms of the Employer Benefit Plan.
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 preexisting medical condition and prior approval is received from the Plan Administrator.
Article III. A. (3)(d) and (e) of the Employer Benefit Plan state:
(3) Physicians’ Services and Other Primary Care
(d) Anesthesia Services
Benefits are provided for the administration of anesthetics provided either in or out of the hospital in surgical or obstetrical cases, when administered and billed by a physician, other than the operating surgeon or his assistant, who is not an employee of, nor compensated by, a hospital, laboratory or other institution.
(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 Employee’s daughter underwent the surgical removal of four complete bony impactions of her maxillary and mandibular (upper and lower) right and left third molars (wisdom teeth) under general anesthesia in the outpatient department of a local hospital.
Article III.A.(1)(g) provides benefits for hospitalization for dental procedures only if such hospitalization is necessary due to a pre-existing medical condition and when prior approval has been received from the Plan Administrator. Article III.A.(3)(d) and Q&A #81-16 (copy enclosed herein) establish the conditions under which anesthesia services are considered a covered benefit. Anesthesia for an oral surgical procedure qualifies under this provision only if it is necessary to assure proper medical management, control, or treatment of the patient in light of the underlying medical condition, and prior approval has been obtained from the Plan Administrator. There is no evidence that the Employee received prior approval from the Plan Administrator in this case.
A Funds’ medical consultant has reviewed the file and advises that the dental work performed in this case is not among the covered oral surgical procedures listed in Article III.A.(3)(e). He further states that the Employee’s daughter’s physician’s records submitted in this case contain no mention of asthma or treatment rendered for asthma, prior to the surgical procedure. Therefore, in the consultant’s opinion, there is insufficient medical documentation to justify hospitalization of the Employee’s daughter based on a pre-existing condition.
In ROD 78-108 (copy enclosed) the Trustees concluded that any charges incurred for oral surgical procedures, other than those provided for in Article III.A.(3)(e), are excluded from coverage. They also concluded that charges for anesthesia and/or hospitalization related to the oral surgical procedure are covered only if medically necessary because of an underlying medical condition, and if prior approval by the Plan Administrator has been obtained. In this case, the surgical procedure was not among those provided for in Article III.A.(3)(e), there was no evidence in the medical record of the pre-existing medical condition, and prior approval was not obtained from the Plan Administrator.
Therefore, the Trustees conclude that the anesthesia charges in connection with the Employee’s daughter’s oral surgery on March 11, 1992 would not be considered an eligible expense under the terms of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for the anesthesia charges resulting from the Employee’s daughter’s oral surgery on March 11, 1992.