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OPINION OF TRUSTEES
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In Re
Complainants: Employee
Respondent: Employer
ROD Case No: 84-420 – October 26, 1987
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., 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 temporomandibular joint syndrome treatment under the terms of the Employer Benefit Plan.
Background Facts
A dentist has determined that the Employee’s daughter had temporomandibular joint syndrome which he characterized as a complicated dentofacial orthopedic problem. The condition was treated with an orthopedic appliance.
The Employer’s standard procedure for reviewing temporomandibular joint (TMJ) syndrome claims includes having a dentist consultant review study models and x-rays of the patient. The Employer has requested this information from the Employee, the dentist and the Employee’s union representative, but the requested information has not been submitted. The Employer states that until it receives documentation that would establish the medical necessity of TMJ treatment, it cannot provide health benefits for the Employee’s daughter’s treatment.
Dispute
Is the Employer responsible for payment of benefits for the Employee’s daughter’s temporomandibular joint syndrome treatment?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of benefits for the Employee’s daughter’s temporomandibular joint syndrome treatment.
Position of the Employer: The Employer is not responsible for payment of benefits for the Employee’s daughter’s temporomandibular joint syndrome treatment because there is inadequate documentation to establish the medical necessity of the treatment provided in this case.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states in part:
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan.
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. (3)(e) of the Employer Benefit Plan stipulates that oral surgical treatment for temporomandibular joint dysfunction is a covered benefit only when it is medically necessary and related to an oral orthopedic problem. Q&A 81-88 (copy enclosed herein) states that the use of external orthopedic appliances is a covered treatment for TMJ syndrome. However, the Introduction to Article III of the Employer Benefit Plan states that the fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under the Plan.
Although the Employer has requested documentation (study models and x-rays) to determine the medical necessity of the Employee’s daughter’s temporomandibular joint syndrome treatment, such documentation has not been provided. The Funds’ physician consultant has reviewed this file and advised that it is impossible to determine whether the treatment being rendered by the dentist is for temporomandibular joint syndrome or for another complaint without reviewing study models and x-rays of the Employee’s daughter’s mouth. Therefore, absent the requested documentation, the medical necessity of the Employee’s daughter’s temporomandibular joint syndrome treatment has not been established and the Employer’s denial of benefits is justified.
Opinion of the Trustees
The Employer is not responsible for payment of benefits for the Employee’s daughter’s temporomandibular joint syndrome treatment as its medical necessity has not been established.
Control Number: 81-88
Subject: Oral Orthopedics
References: Amended 1950 & 1975 Benefit Plans & Trusts,
Article III, Section A (3) (e) and (m), and A (11) (a) 19
Question:
Are benefits provided for treatment of Temporomandibular Joint Dysfunction?
Answer:
No, except when treatment involves:
1. the use of corrective external orthopedic appliances; or
2. corrective surgery to specifically reorient the temporomandibular joint.
If either treatment is to be rendered by an oral surgery, prior approval must be obtained from the Plan Administrator.
Benefits are not provided for treatment for T.M.J. which involves the insertion of dentures.