Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eight tooth extractions (D7140) and an unspecified adjunctive procedure (D9999) provided on February 10, 2021, by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that the removal of these teeth was medically necessary and should be covered. The Plan denied your request. The Plan says the extractions are covered. The cost-sharing has been applied correctly to these services, which were received out-of-network, but the unspecified adjunctive procedure is not covered by your dental benefit.

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. The rules also 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 of the covered Plan allowance for comprehensive dental services after the $100 deductible is met. You may see an out-of-network dental provider, but you may pay more.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested unspecified adjunctive procedure is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified adjunctive procedure (D9999) provided on February 10, 2021, by an out-of-network provider.

The Plan paid $0 for one extraction, $7 for the second extraction, and $28.50 for each of the remaining 6 extractions. You have been asked to pay the remainder of the bill. The out-of-network provider billed $359 for each of the eight extractions. The Plan's allowed amount for each extraction was $57. In-network providers have agreed to accept the Plan's allowed amount as a full payment for this service and not bill you any additional amount, but out-of-network providers do not have this agreement. If you see an out-of-network provider, you may pay more because they are allowed to ask you to pay the full bill beyond what is covered by the Plan. This means that you can be asked to pay $302 ($359 billed amount - $57 Plan's allowed amount = $302 remaining) per extraction on top of your contractual cost-sharing obligation. ($302 x 8 extractions = $2,416).

Extractions are considered a comprehensive dental service. Therefore, you are required to pay 50% coinsurance of the Plan's allowed amount for each procedure after your $100 deductible is met. The Plan paid $0 for the first extraction because you had not met your deductible at the time. After the first extraction, you needed to pay $43 ($100 - $57 = $43) to meet your deductible. $43 of the allowed amount for the second tooth was applied to your deductible. Once this deductible is met, the Plan will start paying their portion, which is also 50% of the allowed amount. Because the amount remaining on the second extraction was $14 ($57 allowed amount - $43 deductible amount = $14), you pay another $7 and the Plan pays $7. You have been asked to pay $28.50 for each of the 6 remaining extractions. ($57 x 50% coinsurance = $28.50). This means that your deductible and cost-sharing amount comes to $278, for a total cost of $2,694. ($2,416 + $278 - $2,694).

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 any additional amount for the eight tooth extractions (D7140) provided on February 10, 2021, by an out-of-network provider.