Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited (problem-focused) oral evaluation (D0140) and extraction (D7140) provided on October 6, 2020.
You asked the Plan to pay for the evaluation and extraction. You say that you realize this provider was out-of-network but feel that these services were urgent due to a broken tooth and severe pain. The Plan denied your request. The Plan says they are able to cover the extraction, however the Plan can only pay up to the amount that they allow for this service, minus your coinsurance. If the provider charges more than the Plan allows for the extraction, the difference in cost is your responsibility. The Plan also says that the limited evaluation exceeds the amount allowed by the Plan. This type of evaluation can only be covered once per plan year, and the Plan paid for you to have a limited exam in September of 2020. Therefore, at the time of service, this benefit was exhausted, and no payment can be made.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50%
coinsurance for extractions, and that you may be asked to pay more if you use an out-of-network provider and they bill an amount that is greater than the Plan's maximum allowable charge for a service.
You have been asked to pay $254.50 for the extraction received from an out-of-network provider. The provider billed the Plan $290, but the Plan only allows a maximum charge of $71 for this service. In-network providers have agreed to bill only for this amount, but out-of-network providers do not have this same agreement with the Plan. When you use an out-of-network provider, you are responsible for the difference in cost between what the Plan allows and what the provider charges. In this case, the difference is $219 ($290 - $71 = $219). In addition, extractions require 50% coinsurance regardless of the network status of the person providing the service. This means that of the allowed $71 amount, you are responsible for $35.50 and the Plan is responsible for $35.50. This brings the total cost to you to $254.50 ($219 + $35.50 = $254.50). This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more or waive the coinsurance for the extraction (D7140) provided on October 6, 2020.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested limited evaluation exceeds the frequency allowed by the Plan. The Plan states that they can only cover one problem-focused evaluation per Plan year. Documentation was provided that shows that the Plan previously paid for a problem-focused exam for you on September 29, 2020. Therefore, we decided that the Plan does not have to pay for the limited (problem-focused) oral evaluation (D0140) provided on October 6, 2020.