File Download: 88-240

Opinion of Trustees
Resolution of Dispute
Case No. 88-240
Page 1 _____________________________________________________________________________

OPINION OF TRUSTEES _____________________________________________________________________________

In Re

Complainant: Respondent: ROD Case No:

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 coverage for oral surgery under the terms of the Employer Benefit Plan.

Background Facts

The Employee’s spouse visited an oral surgeon with complaints of chronic increasing discomfort of the maxillary and mandibular denture-bearing bases, inability to function with her current and previous sets of dentures, and temporomandibular joint (“TMJ”) symptoms. According to the oral surgeon, the Employee’s spouse wanted to have her upper and lower dentures stabilized so that she would be able to chew properly without pain. The oral surgeon diagnosed her as having a mandibular developmental deformity characterized by severe atrophy of the maxilla and mandible and recommended the placement of a mandibular bone plate implant, which he characterized as the most conservative treatment approach. On August 31, 1989, the oral surgeon placed a mandibular bone plate implant and maxillary endosseous implants. This surgery was performed in a hospital on an outpatient basis. Following the surgery, the Employee’s spouse was fitted with replacement teeth.

The Employer has denied benefits for the oral surgeon’s fees, the outpatient hospitalization charges, and the Employee’s spouse’s replacement teeth.

Dispute

Is the Employer required to provide health benefits coverage for the Employee’s spouse’s oral surgery, the related hospitalization, and her replacement teeth?

Positions of the Parties

Employee
Employer
88-240 – May 16, 1990

Opinion of Trustees Resolution of Dispute Case No. 88-240
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Position of the Employee: The Employer is required to provide benefits for the Employee’s spouse’s oral surgery and related good and services, which corrected her TMJ problem, because they were medically necessary to restore her chewing function; the surgery was not cosmetic in nature.

Position of the Employer: The Employer is not required to provide health benefits coverage for the Employee’s spouse 5 oral surgery because the procedures performed do not meet the coverage requirements under the Plan. Q&A 81-88 states that benefits are not provided for TMJ treatment that involves the insertion of dentures. In addition, Q&A 81-15 limits coverage for a mandibular bone staple procedure to the repair of a fractured jaw; it cannot be covered when performed to secure mandibular reconstruction as performed in this case. The Employer further states that Article XX-A Section III G. (21) of the 1988 National Bituminous Coal Wage Agreement (“NBCWA”) specifically excludes benefits for dental implantology.

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 pre-existing medical condition and prior approval is received from the Plan Administrator.

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)

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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. (7) (a) 1. of the Employer Benefit Plan states: (7) Other Benefits

(a) Orthopedic and Prosthetic Devices

Benefits are provided for orthopedic and prosthetic devices prescribed by a physician when medically necessary.

The following types of equipment are covered:

1. Prosthetic devices which serve as replacement for internal or external body parts, other than dental.

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: Discussion

Article III. A. (3) (e) of the Employer Benefit Plan states that benefits are not provided for dental services and specifies the limited oral surgical procedures for which benefits are provided.
Under Article III. A. (3)(e), benefits may be provided for treatment of TMJ dysfunction, but only when medically necessary and related to an oral orthopedic problem. In addition, Q&A 81-88 (copy enclosed herein) states that benefits are provided for the treatment of TMJ dysfunction when treatment involves the use of corrective external orthopedic appliances or corrective surgery to specifically reorient the TMJ. A Funds’ medical consultant has reviewed the information submitted in this case and advised that the procedure performed, the placement of the mandibular bone plate and endosseous implants, is not among the limited oral surgical procedures covered under Article III. A. (3) (e) of the Employer Benefit Plan. The medical consultant further stated that, although the oral surgeon reports that the patient had TMJ complaints, there is no medical documentation to establish that the Employee’s spouse’s surgery was medically necessary for the treatment of TMJ dysfunction.

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According to Q&A 81-15 (copy enclosed herein), charges for other dental and oral surgical procedures may also be covered under the Employer Benefit Plan, but only when the procedure is performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit. One example is the insertion of a mandibular bone staple to repair a fractured jaw. The Employee’s spouse in this case underwent surgical placement of a mandibular bone plate implant to the mandible and endosseous implants to the maxilla for the purpose of attaching replacement teeth to the gums or bones of her mouth. The medical consultant has advised that the medical documentation submitted does not establish that the Employee’s spouse’s surgery was medically necessary as part of the treatment of an illness or injury that is otherwise covered under the Employer Benefit Plan. Consequently, the surgeon’s fees relating to the Employee’s spouse’s oral surgery are not covered under the Employer Benefit Plan.

Article III. A. (1)(g) of the Employer Benefit Plan provides benefits for medically necessary hospitalization when the admission is for an oral surgical procedure listed in Article III. A. (3)(e). Benefits may also be provided for hospitalization for dental procedures if hospitalization is necessary due to a beneficiary’s preexisting medical condition and prior approval has been received from the Plan Administrator. The medical consultant has advised that there is no evidence of a preexisting medical condition that would have necessitated hospitalization for the Employee’s spouse’s surgery. Consequently, the outpatient hospitalization charges related to the Employee’s spouse’s oral surgery are not covered under the Employer Benefit Plan.

Article III. A. (7) (a) 1. of the Employer Benefit Plan specifically excludes benefits for dental prosthetic devices. Therefore, the Employee’s spouse’s replacement teeth are not covered under the Employer Benefit Plan.

The Employer has also stated that dental implants are not covered under its Dental Plan established pursuant to Article XX-A of the Wage Agreement. The exemption granted to the Trustees by the United States Department of Labor only authorizes the Trustees to resolve disputes arising under the terms of the Employer Benefit Plans established pursuant to Article XX of the NBCWA. Inasmuch as dental benefits are provided under Article XX-A of the Wage Agreement, the Trustees may not address this dispute with respect to benefits payable under the Employer’s Dental Plan.

Opinion of the Trustees

The Employer is not required to provide health benefits under the Employer Benefit Plan for the Employee’s spouse’s oral surgery, the related hospitalization, or her replacement teeth.