Opinion of Trustees
Resolution of Dispute
Case No. 88-101
Page 1 _____________________________________________________________________________

OPINION OF TRUSTEES _____________________________________________________________________________

Complainant: Respondent: ROD Case No:

In Re

Employee
Employer
88-101 – April 19, 1989

Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, Trustee.

Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits for dental procedures under the terms of the Employer Benefit Plan.

Background Facts

The Employee had four impacted wisdom teeth removed under general anesthesia. The procedure was performed in the outpatient facility of a hospital because of the severity of the impactions and their proximity to nerves in the Employee’s mouth.

The Employer paid the charges for the oral surgeon’s services and the anesthesiologist’s services up to the scheduled amounts under the Dental Plan. The Employer denied benefits under the Employer Benefit Plan for the balance of the anesthesia charges and the outpatient hospital expenses related to the dental procedures performed on the Employee.

Dispute

Is the Employer required to provide health benefits under the Employer Benefit Plan for the anesthesia and hospital charges associated with the Employee’s dental treatment?

Positions of the Parties

Position of the Employee: The Employer is required to provide health benefits under the Employer Benefit Plan for the anesthesia and hospital charges associated with the Employee’s dental treatment because hospitalization was medically necessary.

Opinion of Trustees Resolution of Dispute Case No. 88-101
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Position of the Employer: The Employer is not required to provide health benefits under the Employer Benefit Plan for the anesthesia and outpatient hospital charges. The oral surgery is not among the limited procedures covered under Article III. A. (3)(e) of the Employer Benefit Plan: Furthermore, no preexisting medical condition necessitated hospitalization for the dental procedures and prior approval was not received from the Plan Administrator. Finally, the oral surgery was not performed as part of the treatment of an otherwise covered illness or injury.

Pertinent Provisions Article III. A. (1)(g) of the Employer Benefit Plan states:

(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) of the Employer Benefit Plan states: (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

Article III. A. (l)(g) of the Plan provides that hospital benefits are provided for (1) beneficiaries admitted for the oral surgical procedures described in Article III. A. (3)(e) of the Plan, if hospitalization is medically necessary, and (2) beneficiaries admitted for dental procedures if hospitalization is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator. A Funds’ medical consultant has advised that the dental work

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performed in this case is not one of the oral surgical procedures identified in Article III. A. (3)(e). The hospital charge is, therefore, not covered under the first section of Article III. A. (1)(g) as cited above.
Benefits are otherwise provided under Article III. A. (1)(g) if hospitalization for dental procedures is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator. The oral surgeon performed the Employee’s extractions in the hospital because of the complexity of the dental procedures, not because of a preexisting medical condition. In addition, the Employee did not obtain prior approval from the Plan Administrator. Accordingly, benefits are not provided for the hospital charge.

Q&A 81-16 (copy enclosed herein) states that physician services, including anesthesia services, provided in connection with a hospitalization for a non-covered dental procedure may be covered if (1) the hospitalization is medically necessary due to a preexisting medical condition or (2) the services are provided for treatment of a medical condition for which benefits are otherwise provided. As discussed above, the hospitalization of the Employee was not necessitated by a preexisting medical condition. In addition, a Funds’ medical consultant found no evidence that the use of anesthesia in this case was related to the treatment of an otherwise covered medical condition. The treatment received by the Employee was limited to the removal of impacted wisdom teeth. Accordingly, benefits are not provided for the anesthesia charge.

Opinion of the Trustees

The Employer is not required to provide benefits under the Employer Benefit Plan for the anesthesia and outpatient hospital charges resulting from the Employee’s dental services on July 8, 1988.