Appeal type: Supplemental Benefit
Decision: Partially Favorable

es not have to pay for the unspecified preventative procedure.
You asked the Plan to pay for the denture and unspecified procedure. You say that these dentures were covered
by your dental plan when you enrolled in the optional supplemental benefit in 2020, and you did not realize
that your benefits had changed in 2021 and no longer included dentures of any kind. You say that you called in
December 2020 to request a new Evidence of Coverage (EOC) for 2021 as you never received one. You
needed this service and would have changed dental insurance if you knew that coverage had changed. You
cannot afford this unexpected bill. The Plan says that dentures are no longer covered in 2021, and these
services/items were denied correctly. The Plan also says that an Annual Notice of Changes (ANOC) was sent
to you on September 11, 2020 to your residence. The health Plan says there is no record of this notice being
returned as undeliverable.
We decided that the Plan has to pay for the denture, minus 20% coinsurance.
We reviewed the Plan's 2021 EOC with a list of specific covered codes and the 2021 ANOC. While it is true
that the requested code D5120 for a denture is not listed as a covered service in 2021, the ANOC provides
conflicting information that is misleading.
The ANOC states that in 2021, the coinsurance for prosthodontics and maxillofacial services will change from
between 20%-50% coinsurance in 2020 to 20% coinsurance in 2021. There is a note to see the schedule of
benefits in the EOC. However, according to the 2021 EOC, no prosthodontic services are covered at all. This is
a major change in coverage that is not addressed in the ANOC, which only indicated a change in the required
cost-sharing for these service categories.
You claim that you contacted the Plan to receive a new book in December 2020. The Plan states that they do
not have a record of this call, and therefore did not send a book. While the ANOC is considered a summary of
changes that are outlined in the EOC, which is the official contract, the ANOC is what was available to you. It
is a poor summary of coverage to indicate that the two categories, maxillofacial services and prosthodontics,
now all require the same coinsurance for covered services rather than to state that an entire category of
services, prosthodontics, is no longer covered in any form. Considering this benefit is also an optional one that
requires an additional premium, this information should be provided more clearly to enrollees.
Considering the ANOC was the primary documentation that was available to you and the document did not
clarify that prosthodontics are no longer covered in any form, or even allude to this fact by removing mention
of the category under the 2021 summary, it is unfair to rely only on the Plan's contract for a decision in this
case. The purpose of an ANOC is to outline and summarize any major changes in coverage, and the
documentation failed to do so in an effective or even suggestive manner. It is misleading to indicate that there
is only a change in coinsurance when in fact an entire category of services is no longer covered.
Documentation from the Plan clearly states that prosthodontic services require 20% coinsurance. Therefore, we
decided that the Plan has to make an exception in this case and pay for the complete lower denture (D5120)
provided on February 12, 2021. Please note that in the future, dentures are not covered by your 2021 dental
benefit.
We also decided that the Plan does not have to pay for the unspecified preventative procedure.
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 items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
unspecified preventative procedure (D1999) provided on February 12, 2021.
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.