ROBERT A. BRYMER, )
vs. ) CASE NO. 84-4207
Respondent. )
Consistent with the Notice of Hearing furnished the parties in this case on December 18, 1984, a hearing was held before Arnold H. Pollock, a Hearing Officer with the Division of Administrative Hearings, in Tallahassee, Florida on January 4, 1985. The issue for consideration at the hearing was whether Petitioner's son's dental treatment is covered by Respondent's Group Health Self Insurance Plan.
For Petitioner: Robert A. Brymer, pro se
For Respondent: Daniel C. Brown, Esquire
On August 28, 1984, Blue Cross/Blue Shield of Florida, administrator of Respondent's Employee's Group Health Self Insurance Plan, notified Petitioner's orthodontist that the proposed orthodontic treatment intended for Petitioner'S son was not covered under the terms of the State Group Plan and would not be paid for by the plan. Thereafter, Petitioner, on September 10, 1984, in a letter to the Secretary of the Department of Administration, petitioned for a hearing to review the claim which he had been notified would be denied.
At the hearing held pursuant to Petitioner's request, Petitioner testified in his own behalf and presented the testimony of Dr. Frank Swerdzewski, his family dentist. Petitioner also introduced Petitioner's Exhibit 1 and 3 - 6.
The parties together introduced Joint Exhibit 1, a copy of the Plan Benefit Document. Respondent introduced no testimony and produced no documentary evidence.
Dr. Swerdzewski, a general dentist in practice in Tallahassee, has been Petitioner's family dentist since 1982. At some time in the latter part of 1983, he saw Petitioner's minor son, Rhett, whom he had seen on various dental problems since 1982 for some minor orthodontic problem. He referred Rhett to an orthodontist but the conclusion drawn was that any work done would be a matter of preference rather than necessity since the mouth was pretty well aligned and it was elective as to whether to do the cosmetic orthodonture or not. Consequently, no orthodontic work was accomplished or planned.
On January 28, 1984, Rhett was riding his bicycle near Petitioner's home when he lost control and fell off the bike, over the handlebars, landing face first on the curb. A neighbor who saw the accident picked Rhett up and carried him to Petitioner's home. At this time, Rhett was bleeding heavily from the mouth.
Fifteen to twenty minutes after the accident took place, Petitioner phoned the dentist. At that time, the dentist was out. When the call was returned an additional fifteen to twenty minutes later, the dentist instructed Petitioner to bring Rhett to the office immediately.
Petitioner did not realize at that time that one tooth had been knocked out of Rhett's mouth. When they arrived at the dentist's office and the wound area was cleaned, it was first discovered that one of Rhett's teeth was missing and it was concluded that the tooth was probably still at the site of the accident.
With that in mind, Petitioner went back to where Rhett had fallen and after a short period of time, located the tooth in the gravel near the side of the road. He returned the tooth to the dentist's office, where it was cleaned and reimplanted in Rhett's mouth. After this work was done, the dentist recommended that Petitioner bring Rhett back a week later and also recommended that Petitioner seek or consult with an orthodontist. This consult was held with Dr. Cummings on February 8, 1984.
Dr. Cummings recommended orthodontic work to correct the problem and that the tooth in question be extracted because in his opinion, the long term prognosis for it was poor.
Petitioner did not want to accept that diagnosis and sought a consultation with another orthodontist, Dr. Campbell, on February 21, 1984. This second orthodontist also recommended extraction and orthodonture indicating that in addition to the reimplanted tooth, the corresponding tooth on the opposite side of the mouth would also have to be extracted to maintain the mouth's midline balance.
Petitioner was still reluctant to have this procedure followed. As a result, Dr. Campbell recommended that Petitioner also discuss the matter with Dr. King, Chairman of the Department of Orthodontics at the University of Florida Dental School. On April 3, 1984, the Petitioner saw Dr. King, who reviewed the case and recommended extraction of the bad tooth and its matching tooth and installation of an orthodontic device.
After the meeting with Dr. King, Petitioner and his wife agreed that the orthodontic work was required and in order that the work could be done, requested an extension from the Blue Cross agency administering the state self
health insurance plan in which Petitioner was enrolled. Blue Cross granted an additional 90 days for filing on May 17, 1984. Once that extension was granted, Petitioner decided to proceed with the treatment not expecting any problem with the insurance coverage. The work was accomplished after school was dismissed for the summer in June, 1984. The two teeth in question ware extracted upon the recommendation of all three orthodontists and braces were installed as appropriate. In August, 1984, the installing orthodontist and Petitioner were notified by Blue Cross/Blue Shield that the work being done would not be covered under the policy.
Under paragraph VIII B of the Benefit Document, dental work "medically necessary" for the alleviation or repair of damage to an insured (including eligible dependents) is covered by the plan only if the work is (1) the result of an accident sustained while the insured is covered, and (2) rendered within
120 days of the accident unless a written explanation is submitted within that period stating extenuating circumstances. At the time of the accident and all times pertinent hereto, Petitioner was a bona fide member of the plan and Rhett was an eligible dependent.
The term "medically necessary" means, in the opinion of the administrator of the program, the service received is required to identify or treat the illness or injury which a physician has diagnosed or reasonably suspects. The service must be (1) consistent with the diagnosis and treatment of the patient's condition, (2) in accordance with standards of good medical practice, and (3) required for reasons other than convenience of the patient or the physician. The fact that a service is prescribed by a practitioner does not necessarily mean that the service is medically necessary. A licensed dentist who performs a procedure covered by the plan is included in the definition of the term "physician."
According to Dr. Swerdzewski, there were three accepted procedures for the treatment of Rhett's condition. The first would be to do nothing at all in which case the reimplanted tooth would ultimately be rejected by the body and lost from the mouth. In this case a space would remain on the gum where the lost tooth was that would allow the remaining teeth to spread to fill the void. In light of the fact that Rhett is still a child, whose jaw is still growing and developing, it would be impossible at this point to determine whether the remaining teeth would stay properly aligned or not.
The second alternative would be to remove the tooth and replace it with a spacer to keep the void open until such time as the jaw was fully grown. At that point, the two teeth adjoining the hole on either side would be prepared for the affixing of a bridge consisting of a false tooth to be inserted in the vacant spot. Since a false tooth or bridge has an effective life span of from
15 to 20 years, given Rhett's current age, it is likely that the bridge would have to be replaced 2 or 3 times during his lifetime. The third alternative would be to follow that procedure followed here. The evulsed tooth, along with its symmetrical pairing on the other side of the mouth, would be removed and an orthodontic device (a brace) installed in the mouth to bring the remaining teeth together to fill the voids. Thereafter, the remaining canine teeth would be modified so that they would appear to be incisors from a cosmetic standpoint. Once this was done it is likely that no further treatment would be required throughout the course of the young man's life except to replace the cosmetic build attached to the modified incisors every so often. This replacement is not a major procedure.
The tooth which was lost in the accident, tooth number 7, was subjected to a root canal by Dr. Swerdzewski prior to being reimplanted in Rhett's mouth. Since the root canal was done, this tooth would no longer discolor. However, subsequent examination of Rhett's mouth showed that tooth number 8 which is located immediately next to number 7, and which was loosened in the accident, shows some evidence of discoloration and may itself need some root canal work done on it.
Though the evulsed tooth was treated and reimplanted, its prognosis at the time was poor. The longer a tooth is out of the mouth, the less chance of successful reimplantation there is when it is done. Dr. Swerdzewski reimplanted the tooth anyway because, in his opinion, individuals heal differently and he thought there was some chance this tooth would reaffix itself in the mouth and be satisfactory. In this case, however, the evulsed tooth was rejected.
When the decision was made to follow the extraction/brace course of treatment and the evulsed tooth and its symmetrical match were pulled, the implanted tooth was seen not to have attached well. It had begun to deteriorate and was at that time in the process of rejection. In Dr. Swerdzewski's opinion, it would have had to come out anyway within the next year even if it did not break prior to that time. In fact, x-rays taken immediately before the tooth was pulled showed some loss of tooth structure and when the tooth was pulled and looked at clearly, the dentist was convinced it would not have stayed in. When Dr. Swerdzerdski took x-rays in March, 1984 there was no evidence of resorption.
In discussing the two reasonable alternatives here, bridgework or orthodonture, Dr. Swerdzewski was of the opinion that while a bridge and caps could be done, this is not normally an acceptable treatment for a child of Rhett's age because of continued growth and mouth development. In addition, one of the adjacent teeth was loose, the area was traumatized, and it "'as likely that there could not be found a good base for attachment of the bridge. Consequently, over the long term, any bridge inserted would have to be replaced and the damage done to good teeth by the preparation for bridgework was not, in his opinion, justified in this case. The long term effect of the use of a bridge on this individual in these circumstances would be more traumatic than would be the course of treatment followed.
It is, also, in the opinion of Dr. Swerdzewski, not good dental practice to do bridgework on patients under the age of 17 or 18 because even if the tooth to which the bridge is attached is fully erupted (grown out) the nerve and root structure of that tooth is not sufficiently developed to support the trauma of the preparation for bridgework. Consequently, Dr. Swerdzewski believes, while it would be dentally acceptable to utilize a space maintainer for the evulsed tooth area until the patient had matured sufficiently to support bridgework, it is not the most appropriate way.
Instead, he chose, consistent with the recommendations of three orthodontists, to take out not only the injured tooth but also a perfectly good tooth which matched it symmetrically on the opposite side of the mouth in order to do the orthodonture. This was done to pull the tooth line together and in the opinion of all four experts, was the best result for the patient, Rhett. In the opinion of Dr. Swerdzewski, it is always better if possible to insert permanent artificialities in the mouth. Also, in Rhett's case, the teeth were pure and in his opinion it is too drastic a measure to damage pure teeth if not absolutely necessary.
Dr. Swerdzewski's testimony is afforded great weight here because his practice includes the formulation and insertion of bridgework, not orthodonture. Having taken the position here that orthodonture was appropriate, he was referring business away from himself to his financial detriment. It was his confirmed opinion, and he acted in accord with it, that bridgework was not appropriate and dentally indicated for this case. No evidence to refute this was presented by Respondent.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties and the subject matter of the proceedings.
Respondent and Petitioner stipulated that Petitioner and his son were covered by the plan at all times material to the issues.
Blue Cross and Blue Shield which administers the plan for the State of Florida has denied coverage of this dental treatment on the basis that the treatment for which the claim was submitted was not covered under the plan as it exists.
Counsel for Respondent agrees that the most important thing for the parents to consider is what is best for their child. However, these legitimate parental concerns cannot necessarily be equated with contractual insurance obligations as called for under the plan.
Section 110.123, Florida Statutes, provides for funding of this plan not only though contributions from insured state employees, but also from tax dollars. In light of this, careful attention is given to defining the commitment undertaken under the plan.
As was stated above, Section VIII B, provides for the coverage of medically necessary dental work which comes about as the result of an accident which took place while the insured is covered and which is rendered within 120 days of the accident unless extended. "Medically necessary" is defined as treatment consistent with the diagnosis of the patient's condition, in accordance with standards of good medical (dental) practice and required for reasons other than the convenience of the patient or the physician. It is also clear that the mere fact that a particular course of treatment is prescribed by a physician (dentist) does not necessarily mean that such service is medically necessary and it is here that Petitioner and Respondent part in their thinking. Respondent contends that the medically necessary service must be required to treat the injury, not merely be an appropriate treatment for the injury. Respondent contends, then, that while the treatment given here was good and appropriate, it was not necessary. Rationale for this position is based on the fact that (a) a bad and a good tooth were removed, (b) good teeth were filed down, and (c) other teeth were built up and these three factors taken together tend to indicate that the procedure followed was more cosmetic rather than necessary. Respondent also contends that the prior orthodontic problem identified before the accident indicates the work here was not necessarily a result of the accident but instead, for the convenience of the patient.
Petitioner, on the other hand, contends that, and there is no dispute, an accident occurred which resulted in a dental problem which required treatment. Petitioner also contends that the orthodontic problem did not exist prior to the accident. He contends that the evidence shows he and his wife had decided to do nothing about the slight cross bite for cosmetic effect prior to
the accident. After the accident, however, a different situation existed.
Here, it is clear that the Petitioner was very much against orthodontic treatment until three orthodontists and his family dentist convinced him that it was the best course of treatment for Rhett considering all factors. In light of this Petitioner contends that the procedures followed do conform to the tests and standards contained in the state plan.
It becomes evident that the basic issue here is the philosophy to be followed in cases of this nature determining whether an individual who in good faith joins a state insurance plan and pays the periodic premiums required thereunder over a period of time prior to need thereafter should be content with less than being restored to a prior position as a result of the insurance coverage in question. In other words, must one who takes state insurance be satisfied with "adequate" treatment if such adequate treatment is not the best treatment within reason. Here, there is no evidence that the treatment for which this claim was submitted was so unusual or so radical as to fall outside the bounds of reasonable dental procedure. Petitioner presented the testimony of his family dentist, and his own, to indicate that three other qualified orthodontists recommended the procedure which was followed. Regardless of how significant this testimony is, the State failed to present any testimony to counter it and it is clear that the evidence presented indicates that the procedure followed was, by far, the most appropriate under the circumstances of this case and goes far beyond merely being recommended by a physician (dentist). Considering all factors, it is obvious that it would be inequitable, unnecessary, and improper to require this Petitioner to accept less than that which was done without some evidence that it was not necessary.
Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore,
RECOMMENDED that the Petitioner herein, ROBERT A. BRYMER, be afforded plan benefits under Respondent's Group Health Self Insurance Plan for treatment rendered his son as a result of the accident which took place on January 28, 1984.
Recommended in Tallahassee, Florida, this 6th day of February, 1985.
ARNOLD H. POLLOCK
Filed with the Clerk of the Division of Administrative Hearings this 6th day of February, 1985.
Dr. Robert A. Brymer 2805 Shamrock North
Daniel C. Brown, Esquire General Counsel
Gilda Lambert, Secretary Department of Administration Carlton Building Tallahassee, Florida 32301
