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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 93-013 – July 12, 1996
Trustees: Thomas F. Connors, Michael H. Holland, Donald E. Pierce, Jr. and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for anesthesia for the removal of impacted wisdom teeth under the terms of the Employer Benefit Plan.
Background Facts
On July 29, 1994, the Employee’s daughter was admitted as a hospital outpatient for the removal of four impacted wisdom teeth. According to the oral surgeon, the hospital setting was required because two of the teeth were close to a sinus wall and there was also a lesion at or in the sinus wall. The dentist submitted a request for prior approval to use the outpatient surgery. The Employer notified the Employee that, if no payment were made under the dental plan, the Employer would, on an exception basis, pay for the outpatient hospital bill only. The Employer further advised the Employee that all other dental expenses would be paid according to the schedule of benefits outlined in the Employer’s dental plan.
The Employer has paid the outpatient hospital bill, but denied the Employee’s request to have the anesthesia bill paid under the medical plan.
Dispute
Is the Employer required to provide medical benefits for the Employee’s daughter’s anesthesia bill?
Positions of the Parties
Position of the Employee: The Employer is required to provide medical benefits for the anesthesia because the service was medically necessary.
Position of the Employer: The Employer is not required to provide medical benefits for the anesthesia because the surgery was dental surgery and, as such, is not covered under the Employer Benefit Plan. Further, this case does not involve the limited circumstances under which the surgery might otherwise be covered pursuant to Q&A 81-16.
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
Article III.A.(11)(a)19. of the Employer Benefit Plan states:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
19. Dental services
Q and A 81-16 states in pertinent part:
Question:
1. Is oral surgery a covered benefit?
2. Are dental services a covered benefit?
3. Are hospitalization charges for semi-private room and board related to a non-covered dental procedure covered under the Plan?
4. Are benefits provided for the medically necessary services (enumerated in Article III, Section A (1), (2) and (3)) in connection with hospitalization for a non-covered dental procedure?
5. Are benefits provided for physician services (enumerated in Article III, Section A (3)) in connection with a hospitalization for a non-covered dental procedure?
Answer:
1. Yes, if such surgery receives the prior approval of the Plan Administrator and is performed in a hospital and hospitalization is medically necessary, benefits are provided for oral surgery treating
tumors of the jaw
fractures of the jaw, including reduction and wiring
fractures of facial bones
frenulectomy, when related to ankyloglossia
temporomandibular joint dysfunction, only when medically necessary and related to an oral orthopedic problem.
biopsy of lesions of the oral cavity
2. No
3. & 4. No, except when, 1) hospitalization is medically necessary because of pre-existing medical condition, and 2) prior authorization has been obtained from the Plan Administrator.
5. No, except for the treatment of a medical condition for which benefits would otherwise be provided.
Discussion
Article III.A.(3)(e) of the Employer Benefit Plan limits the oral surgical procedures for which benefits are provided. Inpatient hospital benefits also are provided when hospitalization for a dental procedure is necessary due to a beneficiary’s preexisting medical condition, and when prior approval has been received from the Plan Administrator.
A Funds’ medical consultant has reviewed the information submitted by the oral surgeon and advises that the patient’s surgery is not an oral surgical procedure covered under Article III.A.(3)(e) of the Plan. The consultant further advises that there is no supporting medical documentation that the lesion at or near the sinus wall constituted a pre-existing medical condition that would require hospitalization.
Since the Employee’s daughter was not admitted as an inpatient, her surgery was not one of the covered oral surgical procedures listed in Article III. A. (3) (e), and there is no evidence of a preexisting medical condition, the requirements for coverage under Article III. A. (1) (g), and discussed in Q&A 81-16, were not met. Therefore, although the Employer has, on an exception basis, provided benefits for the outpatient hospital bill, it is not required to provide benefits for the Employee’s daughter’s anesthesia.
Opinion of the Trustees
The Employer is not required to provide benefits for the Employee’s daughter’s anesthesia services.