Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to make additional payment for the periodic oral evaluation, prophylaxis, one
anterior resin-based composite, and posterior resin-based composite. We decided that the Plan does not have to
pay in full for the periodic oral evaluation, prophylaxis, one anterior resin-based composite, and posterior resinbased
composite, or pay for the additional anterior resin-based composite.

You asked the Plan to pay for the periodic oral evaluation, prophylaxis, two anterior resin-based composites,
and posterior resin-based composite provided on April 4, 2019, and April 9, 2019. You say that you do not feel
you should have to pay back the money that the Plan reimbursed you with. The Plan says that there was an
overpayment of $185.25, and the Plan has the right to recover payments made in error.

We decided that the Plan has to make additional payment for the periodic oral evaluation, prophylaxis,
one anterior resin-based composite, and posterior resin-based composite.

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 contract states that you are responsible for a 50% coinsurance for periodic oral exams and prophylaxis, and
a 55% coinsurance for composite fillings that are received OON. The contract also says that amalgam and/or
composite fillings are limited to 2 per year. The EOC does not clearly state that you can expect to pay more
than the coinsurance amount when services are received OON. You reasonably believed that the Plan would
pay a 50% coinsurance for the periodic oral exam and prophylaxis, and a 55% coinsurance for the two resinbased
composites. Therefore, we decided that the Plan has to make additional payment for the periodic oral
evaluation, prophylaxis, one anterior resin-based composite, and posterior resin-based composite.

We also decided that the Plan does not have to pay in full for the periodic oral evaluation, prophylaxis,
one anterior resin-based composite, and posterior resin-based composite, or pay for the additional
anterior resin-based composite.

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, you must pay a 50% coinsurance for
periodic oral exams and prophylaxis, and a 55% coinsurance for composite fillings that are received OON. The
contract also says that amalgam and/or composite fillings are limited to 2 per year. The record shows that you
received three resin-based composites on April 9, 2019, two of which were covered by the Plan, and your
amalgam and/or composite fillings benefit had been exhausted. Therefore, we decided that the Plan does not
have to pay in full for the periodic oral evaluation, prophylaxis, one anterior resin-based composite, and
posterior resin-based composite, or pay for the additional anterior resin-based composite.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.

Please Note: The initial claims were voided and re-inventoried by the Plan. The payment you made was unable
to be transferred to the corrected claim, resulting in the overpayment amount of $185.25 being sent back to
you.