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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 93-034 – October 3, 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 mandibular osteotomy under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s daughter received orthodontic treatment (braces) from January 1990 to October 1992. Prior to the initiation of this treatment, she experienced episodes of popping of the temporomandibular joints and temporal headaches. These symptoms continued intermittently throughout the period of orthodontic treatment. After her braces were removed, she had no active symptoms of temporomandibular joint disease (TMJ) until January 1994 when she again noted popping on both sides and suffered from headaches two or three times a week. Her dentist’s evaluation indicated a significant shift in her occlusion had developed and noted a deviation of her mandible to the left side. The dentist referred her to an oral surgeon who recommended that she undergo mandibular and maxillary osteotomies. A request for preauthorization of benefits was submitted to the Employer for approval of surgical benefits. The Employer approved benefits in the amount of $900.00 under its dental plan but denied benefits under its medical plan.
The Employee requested reconsideration of the denial of benefits under the medical plan. The denial was sustained on reconsideration.
Dispute
Is the Employer required to provide benefits under the Employer Benefit Plan for the Employee’s daughter’s proposed osteotomy surgery?
Positions of the Parties
Position of the Employee: The Employer is required to provide medical benefits for the Employee’s daughter’s proposed oral surgery because it is needed to treat medical problems, i.e., headaches and temporomandibular joint disease.
Position of the Employer: The Employer is not required to provide medical benefits for the Employee’s daughter’s proposed oral surgery because it is dental surgery and as such, is not covered under the Employer Benefit Plan. In addition, 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.(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) 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. 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&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. Article III.A.(1)(g) provides benefits for a medically necessary hospitalization when the admission is for an oral surgical procedure listed in Article III.A.(3)(e). Inpatient hospital benefits are also 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 and advises that the patient’s proposed osteotomy surgery is not among the limited oral surgical procedures covered under Article III.A.(3)(e) of the Plan. The consultant further advises that there is no medical documentation of temporomandibular joint dysfunction that meets the medical necessity requirements of the Employer Benefit Plan, nor is there any evidence of a preexisting medical condition that would require hospitalization for this procedure. Accordingly, the Employer is not required to provide health benefits for the Employee’s daughter’s proposed oral surgery.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide health benefits coverage for the Employee’s daughter’s proposed oral surgery.