1983年2月22日

(Opinion issued in letter form; name and address deleted)

Re: Opinion of Trustees Resolution of Dispute

情况下没有. 81-139

Pursuant to Article IX of the United Mine Workers of America 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed your Request for Advisory Opinion concerning coverage under the Employer’s Benefit Plan for your oral surgery and for the anesthesiologist’s charges.

第三条. A. (3)(e) of your Employer’s Benefit Plan specifically excludes benefits for dental services, with the exception of the following limited oral surgical procedures if performed by a dental surgeon or oral 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, 只有在医学上

necessary and related to an oral orthopedic problem Biopsy of lesions of the oral cavity

根据第三条. A. (1)(g) of the Employer’s Benefit Plan, 6月7日修订, 1981, benefits are provided for hospitalization, 如果有必要的话, for the limited oral surgical procedures listed in 第三条. A. (3)(e), and for dental procedures only if the hospitalization is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator. A Fund’s medical consultant has determined that your oral surgery was not one of the procedures listed in 第三条. A. (3)(e), and that you had no preexisting medical condition. Therefore, your Employer is not responsible for payment of charges for your oral surgery.

Q&A #81-16, 附件, provides that physician services, including anesthesia services, are a covered benefit only when they are for the treatment of a medical condition for which benefits would otherwise be provided. Because you did not have an otherwise covered medical condition, benefits are not provided for anesthesia services performed in connection with your dental procedures.

真诚地,
哈里森·库姆斯，主席

主题:引用:

问题:

约翰J. 奥康奈尔,受托人

Paul R. 迪恩,受托人
控制号:81-16

Hospitalization and Professional Services for Dental Procedures

修改1950 & 1974年福利计划 & 信托皇冠搏彩中心网站,
第三条, Sections A (1) (a), A (3) (d) and (e) and A (11) 19

1. Is oral surgery a covered benefit?
2. Are dental services a covered benefit?
3. Are hospitalization charges for semi-private room and board related to a non- covered dental procedure covered under the Plan?
4. Are benefits provided for the medically necessary services (enumerated in 第三条, 第A(1)节, (2) and (3) in connection with hospitalization for a non-covered dental procedure?
5. Are benefits provided for physician services (enumerated in 第三条, Section A (3)) in connection with a hospitalization for a non-covered dental procedure?

答:

1. 是的, if such surgery receives the prior approval of the Plan Administrator and is performed in a hospital and hospitalization is medically necessary, benefits are provided for oral surgery treating

颌骨肿瘤
o fractures of the jaw, including reduction and wiring
o fractures of the facial bones
o frenulectomy when related only to ankyloglossia
o temporomandibular Joint Dysfunction, 只有在医学上 necessary and

related to an oral orthopedic problem o biopsy of lesions of the oral cavity

2. No.

3. & 4. No, 除非, 1) hospitalization is medically necessary because of pre-existing medical condition, and 2) prior authorization has been obtained from the Plan Administrator.

5. No, except for the treatment of a medical condition for which benefits would otherwise be provided.