Opinion of Trustees Resolution of Dispute Case No. 81-409
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(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees Resolution of Dispute
Case No. 81-409
March 1, 1984
Pursuant to Article IX of the United Mine Workers of America 1950 Benefit Plan and Trust, aid under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed your Request for Resolution of Dispute concerning coverage of physician services and hospitalization for your son’s oral surgery under the Employer’s Benefit Plan.
Article III. A. (33(e) of your Employer’s Benefit Plan specifically excludes benefits for dental services, except for the following limited oral surgical procedures, when performed by a dental surgeon or oral 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 lesions of the oral cavity
Article III. A. (13(g) of your Employer’s Benefit Plan provides benefits for medically necessary hospitalization when the admission is for an oral surgical procedure listed in Article III. A. (33(e). Benefits are also provided when hospitalization for a dental procedure is necessary due to a beneficiary’s pre-existing medical condition, and Men prior approval has been received from the Plan Administrator.
According to Q&A #81-15, attached hereto, certain dental and oral surgical procedures are covered under the Employer’s Plan only when performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit.
Q&A #81-16, a copy of which is enclosed, provides that physician services, including anesthesia services, are a covered benefit only when they are for the treatment of a medical condition for which Benefits would otherwise be provided.
Although the dentist, anesthesiologist and pediatrician involved in your sons case agree that hospitalization and general anesthesia were necessary to overcome the lack of cooperation due to
Opinion of Trustees Resolution of Dispute Case No. 81-409
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his age in order to facilitate the dental procedures, none of these providers has indicated that your son had a pre-existing medical condition that would justify his admission as medically necessary.
A Funds’ medical consultant has reviewed the medical evidence submitted and advised us that your son’s oral surgery is not one of the procedures listed in Article III. A. (3)(e). In addition, the consultant is of the opinion that your son does not have a Pre-existing medical condition which would satisfy the requirements of Article III. A. (1)(g), and the dental services he received cannot be considered part of the treatment of an otherwise covered medical condition.
Therefore, your Employer, is not responsible for payment for physician services, including anesthesia services, or for hospitalization charges related to your son’s oral surgery in this instance.
Enclosure
Sincerely,
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee
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