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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 88-317 – September 25, 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 treatment of temporomandibular joint syndrome for an Employee’s son under the terms of the Employer Benefit Plan.

Background Facts

In December 1989, a dentist who specializes in temporomandibular joint disorders diagnosed the Employee’s son as having temporomandibular joint syndrome caused by a deviation of his mandible to the left resulting in displacement of the right and left condyle and in the rotation of the Employee’s son’s lower jaw. The dentist states that the Employee’s son had presented with symptoms that include the following: headaches, right jaw pain, hyperactivity, sinus/allergy troubles and digestive problems. The treatment prescribed for the Employee’s son’s disorder was a combination of orthotic splint/orthopedic appliances to reposition the mandible.

The Employer states that it followed its standard procedure for reviewing temporomandibular joint syndrome claims. A dental consultant reviewed the available notes and narrative provided by the oral surgeon. The consultant determined that the services performed were orthodontic in nature and that the diagnosis of temporomandibular joint syndrome could not be confirmed. Therefore, the Employer denied benefits for the Employee’s son’s treatment under the Employer Benefit Plan.

Dispute

Is the Employer required to provide benefits for the Employee’s son’s temporomandibular joint syndrome treatment?

Positions of the Parties

Position of the Employee: The Employer is required to provide benefits for the Employee’s son’s temporomandibular joint syndrome treatment because such treatment is covered under the Employer Benefit Plan.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s son’s temporomandibular joint syndrome treatment because there is inadequate medical documentation to establish its medical necessity and the treatment rendered was orthodontic in nature.

Pertinent Provisions

The Introduction to Article III states:

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:

(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)
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

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. Article III. A. (3)(e) of the Employer Benefit Plan, as interpreted by the Trustees in Q&A 81-88 (copy enclosed herein], provides benefits for the use of corrective external orthopedic appliances as a treatment for temporomandibular joint dysfunction only when such treatment is medically necessary and related to an oral orthopedic problem.

The Employer’s insurance carrier’s dental consultant has reviewed documentation provided by the dentist concerning the Employee’s son’s treatment. The consultant determined that the treatment was orthodontic in nature and that temporomandibular joint derangement was not confirmed by the information provided. A Funds’ medical consultant has reviewed the information submitted in this case and has advised that the documentation provided does not establish the presence of a temporomandibular joint disorder that would require treatment with an external orthopedic appliance. The consultant has advised that treatment with an external orthopedic appliance in this case was orthodonic in nature. Inasmuch as the medical necessity of the Employee’s son’s temporomandibular joint syndrome treatment has not been established, the Employer’s denial of benefits is justified.

Opinion of the Trustees

The Employer is not required to provide benefits for the Employee’s son’s temporomandibular joint syndrome treatment, as its medical necessity has not been established.