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受托人的意见
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在再保险
原告: 员工
被申请人: 雇主
ROD案例编号: 07-0006 - 2007年9月19日
受托人: 迈克尔W. 巴克纳,. 弗兰克·邓纳姆，迈克尔·H. Holland和Elliot A. 西格尔.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the 雇主 Benefit Plan.
背景事实
Complainant’s dentist and primary care physician both recommend 那 Complainant have his remaining teeth extracted due to advanced periodontal disease and generalized tooth decay. 申诉人患有多种疾病, 包括胰岛素依赖型2型糖尿病, 高血压, 高脂血症, 丙型肝炎, 和asplenism, 那, 申诉人的初级保健医生认为, have been significant contributing factors to Complainant’s periodontal and tooth disease. Respondent has referred Complainant to the Dental Plan and maintains 那 the requested procedures are not covered under the 雇主 Benefit Plan.
争端
Is the Respondent required to provide coverage for the Complainant’s dental work under the 雇主 Benefit Plan?
双方立场
Position of the 原告: Complainant’s underlying medical conditions, 雇主福利计划涵盖哪些项目, 会引起牙周病吗. 像这样, the dental work requested by the Complainant’s dentist and primary care physician should also be covered by the 雇主 Benefit Plan.
Position of the 被申请人: Dental services are not covered under the 雇主 Benefit Plan, 第三条A款所列以外的. (3) (e), and are specifically excluded by the Plan in 第三条A (11) (a) 19. Respondent is not required to provide benefits for the requested dental procedures.
相关的规定
第三条福利待遇
…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, 或计划另有规定. The fact 那 a procedure or level of care is prescribed by a physician does not mean 那 it is medically reasonable or necessary or 那 it is covered under this Plan. 在确定合理性和必要性的问题上, 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. The benefits described in this Article are subject to any precertification, 处方药处方(PDP)要求, and other utilization review requirements implemented pursuant to Article IV. Covered services 那 are medically necessary will continue to be provided, 和相应的, 而福利金则受规定的限额限制, this paragraph shall not be construed to detract from plan coverage or eligibility as described in this Article III.
第三条A. 雇主福利计划第(1)(g)条规定:
A. 健康的好处
(1)住院医疗福利
(g)口腔外科/牙科手术
Benefits are provided for a Beneficiary who is admitted to a hospital for the oral procedures described in subsection (3) (e) provided hospitalization is medically necessary.
Benefits are also provided for a Beneficiary admitted to a hospital for dental procedures only if hospitalization is necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator.
第三条A. 雇主福利计划第(3)(e)条规定:
A. 健康的好处
(3)医生服务和其他初级保健
(e)口腔外科
牙科服务不提供福利. 然而, benefits are provided for the following limited oral surgical procedures if performed by a dental surgeon or general surgeon.
颌骨(上颌骨和下颌骨)布线的肿瘤
Frenulectomy when related only to ankyloglossia (tongue tie)
口腔活组织检查
颌骨骨折，包括复位和
面骨骨折
颞下颌关节功能障碍, only when medically necessary and related to an oral orthopedic problem.
因事故需要牙科服务
第三条A. 雇主福利计划第(11)(a) 19条规定:
A. 健康的好处
(11)一般除外条款
(a) In addition to the specific exclusions otherwise contained in the Plan, 以下情况也不提供福利:
19. 牙科服务
讨论
第三条A of the 雇主 Benefit Plan expressly excludes the provision of benefits for dental procedures, except for those specific oral surgeries listed in 第三条A. (3) (e). 的资金’ Medical Director has reviewed the submitted documentation and has determined 那 the procedures requested by the Complainant’s physician and dentist are dental procedures not among those oral surgical procedures covered by 第三条A. (3) (e), nor are they dental procedures needed as the result of an accident. Although Respondent does not dispute the assertion by Complainant’s physician 那 Complainant’s underlying medical condition may have
contributed to the periodontal and tooth disease for which the extractions are needed, the Funds’ Medical Director has determined 那 the requested procedures are not treatments for those underlying medical conditions covered under the 雇主 Benefit Plan.
受托人的意见
The 雇主 is not responsible for providing health benefits under the 雇主 Benefit Plan for the 员工’s requested dental procedures.