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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 88-311 – November 14, 1990

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 benefits for a craniomandibular evaluation for an Employee’s spouse under the terms of the Employer Benefit Plan.

Background Facts

The Employee’s spouse was referred by her physician to a dentist for a craniomandibular evaluation after complaining of pain in the left temporomandibular joint upon chewing. On October 12, 1989, the dentist took a series of x-rays of the temporomandibular joints and diagnostic models of the number, kind and arrangement of teeth in the mouth. On October 23, 1989, the Employee’s spouse underwent a neuromuscular evaluation which included electromyography, computerized mandibular scan, transcutaneous electrical neural stimulation and sonograms of the temporomandibular joints. On October 30 and November 15, 1989, the dentist performed a clinical evaluation and consultation. The dentist suggested a total of fourteen diagnoses, one of which was temporomandibular joint (TMJ) disorder. He then recommended that the Employee’s spouse have independent evaluations performed by doctors of neurology, orthopedics, oral surgery and osteopathy who treat craniomandibular disorders; additional diagnostic testing which would include a CT scan and MRI; and the continuation of the conservative treatment with a soft diet, moist heat to the right and left joints, and anti-inflammatory medication and analgesics.

The Employer has denied benefits for the Employee’s spouse’s craniomandibular evaluation on the grounds that the services performed were dental services that are not covered under the Employer Benefit Plan. The Employer has also determined that the services rendered on October 23, 1989 were experimental and investigative procedures, and as such would not be covered under the Employer Benefit Plan in any event.

Dispute

Is the Employer required to provide benefits for the craniomandibular evaluation performed on the Employee’s wife on October 12, 23, 30 and November 15, 1989?

Positions of the Parties

Position of the Employee: The Employer is required to provide benefits for the Employee’s wife’s craniomandibular evaluation because she has TMJ syndrome and needs treatment.

Position of the Employer: The Employer is not required to provide benefits for the Employee’s wife’s craniomandibular evaluation because the services performed are dental in nature and dental services are not covered under the Employer Benefit Plan. Moreover, the tests performed on October 23, 1989 are experimental and investigative services, which are also excluded from coverage under the Plan.

Pertinent Provisions

The Introduction to Article III of the Employer Benefit Plan provides:

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. In determining questions of reasonableness and necessity, due consideration will be given to the customary practices of physicians in the community where the service is provided. Services which are not reasonable and necessary shall include, but are not limited to the following: procedures which are of unproven value or of questionable current usefulness; procedures which tend to be redundant when performed in combination with other procedures; diagnostic procedures which are unlikely to provide a physician with additional information when they are used repeatedly; procedures which are not ordered by a physician or which are not documented in timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care. Covered services that are medically necessary will continue to be provided, and accordingly this paragraph shall not be construed to detract from plan coverage or eligibility as described in this Article III.

Article III. A. (3)(j) and (o) of the Employer Benefit Plan provide:

(3) Physicians’ Services and Other Primary Care

(j) Laboratory Tests and X-rays

Benefits will be provided for laboratory tests and x-rays performed in a licensed laboratory when ordered by a physician for diagnosis or treatment of a definite condition, illness or injury.

(o) Primary Medical Care – Miscellaneous

2. Benefits are provided for immunizations, allergy desensitization injections, pap smears, screening for hypertension and diabetes, and examinations for cancer, blindness, deafness, and other screening and diagnostic procedures when medically necessary.

Article III. A. (11)(a)19. of the Employer Benefit Plan provides:

(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

The Introduction to Article III of the Employer Benefit Plan states that covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury. 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. The Introduction further states that services which are not reasonable and necessary include procedures which are of unproven value or of questionable current usefulness.

Under Article III. A. (3)(j) and Article III. A. (3)(o) 2. of the Employer Benefit Plan, benefits are provided for laboratory tests, x-rays and other screening and diagnostic procedures when medically necessary. Article III. A. (11)(a)19. of the Plan states that benefits are not provided for dental services. A Funds’ medical consultant has reviewed this case and has advised that the tests and procedures performed on the Employee’s spouse were dental in nature. The consultant has advised that there is no medical documentation to establish that the procedures performed on the Employee’s spouse were medically necessary for the diagnosis of a medical condition. The medical consultant also stated that he is in agreement with the Employer’s determination that the tests and procedures performed on October 23, 1989 are not recognized by the medical community as having proven value in the diagnosis of temporomandibular joint disorders and that when such procedures are used for this purpose, they would be classified as experimental at best.

Inasmuch as the craniomandibular evaluation performed on the Employee’s spouse was not medically necessary for the diagnosis of a medical condition, the Employer is not required to provide benefits for the evaluation under the Employer Benefit Plan.

Opinion of the Trustees

The Employer is not required to provide benefits for the craniomandibular evaluation performed on the Employee’s wife on October 12, 23, 30 and November 15, 1989.