____________________________________________________________________________
OPINION OF TRUSTEES
____________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 93-091 – March 17, 2000
Trustees: A. Frank Dunham, Michael H. Holland, Donald E. Pierce, Jr. and
Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for oral surgery under the terms of the Employer Benefit Plan.
Background Facts
On March 28, 1997, at a facial surgery center, the Employee had bone grafts from his hip implanted to augment his maxilla which was severely atrophied. On September 5, 1997, he received four dental implants which are utilized for the purpose of attaching replacement teeth to the gums or bones of the mouth. Coverage for these procedures was reviewed under the Employer’s dental plan.
The Employee claims that coverage for his oral surgical procedures should be covered as a medical procedure not as a dental procedure because during surgery it was found that his sinus walls were extremely thin and a small pathologic fracture was present.
Dispute
Is the Employer required to provide medical benefits coverage for the Employee’s oral surgical procedure and dental implants?
Positions of the Parties
Position of the Employee: The Employer is required to provide medical benefits for the Employee’s oral surgery and dental implants because of the critical condition of his sinus.
Position of the Employer: The Employer is not required to provide medical benefits for the services provided because they are covered under the dental plan and are not among the procedures covered under Article III A. (3) (e) of the Employer Benefit Plan.
Pertinent Provisions
Article III. A. (3) (e) of the Employer Benefit Plan states:
ARTICLE III BENEFITS
A. Health Benefits
(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 a direct result of an accident
Article III A. (7) (a) 1. of the Employer Benefit Plan states, in pertinent part:
(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 specifies the limited oral surgical procedures for which benefits are provided. Dental services are otherwise excluded under Article III. A. (11) (a) 19. of the Plan. In addition, Article III. A. (7)(a) 1. of the Plan specifically excludes benefits for dental prosthetic devices.
A Funds’ medical consultant has reviewed the medical evidence submitted and advised that the basic procedure performed was an oral surgical procedure and is not among the oral surgical procedures covered under Article III. A. (3)(e) of the Employer Benefit Plan. The medical consultant has further stated that based on the documentation submitted, any surgical work in relation to the sinus problems or fracture was minor and incidental compared to the overall bone augmentation of the maxilla and subsequent dental implants. Therefore, the Employer is not required to provide benefits under the Employer Benefit Plan for the oral surgical procedure or the dental implants.
Opinion of the Trustees
The Employer is not required to provide health benefits under the Employer Benefit Plan for the Employee’s oral surgical procedure or dental implants.