Issued and entered January 31, 2003 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On October 12, 2002, XXXXXXXXXX, on behalf of her son XXXXXXX (Petitioner), filed a request for external review with the Commissioner of the Office of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act (PRIRA), MCL 550.1901 et seq. After an assessment of the material submitted, the Commissioner accepted the request.
The issue in this matter is contractual in nature. There is no medical issue; therefore, review by an Independent Review Organization (IRO) is not required. The Commissioner reviews contractual issues under MCL 550.1911(7). On XXXXXXXXXXXXXXXX, the Office of Financial and Insurance Services (OFIS) received from Blue Cross Blue Shield of Michigan (BCBSM) the information it used to make its adverse determination in Petitioner’s case.

II
FACTUAL BACKGROUND

Petitioner is a BCBSM member. He does not have dental coverage with BCBSM. He seeks coverage for XXXXXXXXXXXX, dental surgery to remove four impacted molars. He did not undergo the dental surgery in a hospital setting, and no other medical condition had any influence on his receipt of the service. BCBSM denied Petitioner coverage for the procedure, because it did not coincide with hospitalization for a hazardous medical condition. Petitioner exhausted BCBSM’s internal grievance process, and BCBSM issued a final adverse determination in his case on October 9, 2002.

III
ISSUE

Did BCBSM properly deny Petitioner coverage for dental surgery to remove four impacted molars?

IV
ANALYSIS

Petitioner’s Position

Petitioner claims that BCBSM should cover his dental surgery, because the removal of impacted teeth is a covered benefit, according to the booklet entitled “Your Benefits Guide.” The booklet states:

Basic Coverage Exclusions

• Dental surgery other than for the removal of impacted teeth or multiple extractions when the patient must be hospitalized for the surgery because a concurrent medical condition, such as a heart condition, exists

[Bold emphasis added.]

Petitioner claims this language excludes dental surgery from coverage, with two exceptions: (1) dental surgery for impacted teeth, or (2) multiple extractions requiring hospitalization for the surgery because of a concurrent medical condition. Because the dental surgery at issue in this case was for the removal of impacted teeth, Petitioner believes the procedure qualifies as a covered benefit. Therefore, Petitioner argues the Commissioner should reverse BCBSM’s final adverse determination in this matter.

BCBSM’S Position

BCBSM claims that it properly denied Petitioner coverage for dental surgery, because he did not undergo the procedure in a hospital due to another medical condition. BCBSM notes that Petitioner’s current benefit contract—the HMS Comprehensive Hospital Medical Surgical Certificate—states at page4.3 as follows:

• Dental surgery is payable only for:

- Multiple extractions or removal of unerupted teeth, alveoloplasty or gingivectomy performed in a hospital when the patient has an existing concurrent hazardous medical condition;

- Surgery on the jaw joint; or

- Arthrocentisis performed for the reversible or irreversible treatment of jaw joint disorders.

BCBSM asserts this language establishes that it covers dental surgery for tooth extractions only when the member is in a hospital because of a medical reason other than the extraction itself. When he underwent dental surgery, Petitioner was not in a hospital and he was nor suffering from an existing concurrent hazardous medical condition. Therefore, the Commissioner should uphold BCBSM’s final adverse determination in this matter.

Commissioner’s Review

The Commissioner carefully reviewed the arguments and documents the parties submitted. The focus of this analysis is whether dental surgery for multiple tooth extractions was a covered benefit, according to Petitioner’s contract with BCBSM in effect at the time he underwent the procedure. The Series MSE Group Benefit Certificate controlled Petitioner’s coverage on XXXXXXXXXXXXX—the date of service. The Certificate states at page 13:

Limitations and Exclusions

3. Benefits for hospital services are not available for dental care or treatment except for multiple extractions or the removal of one or more unerupted teeth, alveoloplasty or gingivectomy and only when a concurrent hazardous medical condition exists that requires the hospitalization.

This language clearly and unambiguously limited Petitioner’s coverage for dental care in two ways. First, the Certificate limited the type of dental coverage he was eligible for to a list of specific services. Multiple extractions, removal of unerupted teeth, alveoloplasty, and gingivectomy were the only services that could possibly qualify for coverage. Second, the Certificate limited the circumstances under which dental care was eligible for coverage. Dental coverage was only available to Petitioner if he obtained an eligible dental service while he was in a hospital because of a separate medical condition.

Petitioner’s interpretation of his coverage mistakenly applies the requirement of hospitalization for a concurrent medical condition to only certain dental services, and not to dental surgery for impacted teeth. However, the terms of the Series MSE Group Benefit Certificate definitely applies that requirement to any coverage for dental care. Petitioner focuses on the language in his benefits booklet, but that pamphlet was not a part of his contract with BCBSM. Even if it was a part of the contract, the language Petitioner cites from the benefits booklet only reinforces the requirement that any dental benefits exist during hospitalization for a concurrent medical condition only.

In the case at hand, Petitioner had surgery to remove four impacted molars. The procedure was clearly an eligible dental service, as it involved multiple tooth extractions. However, he did not undergo the surgery while he was in the hospital because of a concurrent medical condition. Therefore, Petitioner’s surgery does not qualify as a covered benefit. It did not meet both of the conditions for coverage for dental care. Accordingly, the Commissioner finds that BCBSM’s final adverse determination in this matter is valid.

IV
ORDER

The Commissioner ORDERS that BCBSM’s XXXXXXXXXXX, final adverse determination in Petitioner’s case is upheld. BCBSM properly denied coverage of Petitioner’s XXXXXXXXXX dental surgery for removal of four impacted molars.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.