_____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
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 oral surgery under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse has mandibular retrognathia, a deformity of the facial skeleton. Her dental surgeon has recommended that she undergo orthognathic surgery to reposition the underlying bone structures.
A Predetermination of Benefits was submitted to the Employer’s dental plan for approval of the surgery. After review by an independent dental consulting firm, the Employer denied dental benefits for the surgery, stating that the consultant recommended a conventional prosthesis be applied in lieu of surgery.
The Employee’s request that oral surgery benefits be provided under the medical portion of the Employer Benefit Plan has been denied by the Employer.
Dispute
Is the Employer required to provide oral surgery benefits for the Employee’s spouse’s orthognathic surgery?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the spouse’s oral surgery because it is medically necessary.
Employee
Employer
93-016 – June 6, 1996
Opinion of Trustees ROD Case No. 93-016 Page 2
Position of the Employer: The Employer is not required to provide benefits for the spouse’s oral surgery because it is not one of the oral surgery procedures covered under the Employer Benefit Plan.
Pertinent Provisions
Article III. A. (3) (e) 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 a direct result of an accident
Discussion
Article III.A.(3)(e) limits covered oral surgery to those procedures that are specifically listed.
A Funds’ medical consultant has reviewed the documentation and has concluded that the Employee’s spouse’s proposed orthognathic surgery is not one of the oral surgical procedures covered by Article III.A.(3)(e), nor is it a treatment for an illness or injury that is otherwise a covered benefit. Therefore, consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for the proposed orthognathic surgery.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide medical benefits for the Employee’s spouse’s proposed orthognathic surgery.