Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the panoramic x-ray (D0330), two surgical extractions (D7210 x2), first 15 minutes of deep sedation/general anesthesia (D9222), and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223). We decided that the Plan does not have to pay for the two additional surgical extractions (D7210 x2), simple extraction (D7140), and therapeutic parenteral drug (D9610).
You asked the Plan to pay for the panoramic x-ray (D0330), simple extraction (D7140), four surgical extractions (D7210 x4), first 15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15 minute increment of deep sedation/general anesthesia (D9223), and therapeutic parenteral drug (D9610). You say that you believe these services should be covered under your medical insurance. The Plan says that the treating provider has chosen to opt out of Medicare. The Plan also says that this means this provider who rendered these services does not and is not permitted to send claims to Medicare or Medicare Advantage plans, except for emergency or urgent care services.
We decided that the Plan has to pay for the panoramic x-ray (D0330), two surgical extractions (D7210 x2), first 15 minutes of deep sedation/general anesthesia (D9222), and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223).
The Plan follows Medicare rules. Medicare rules say that an MA organization may make payment to a physician or practitioner described in paragraph (a) of this section for services that are not basic benefits but are provided to a beneficiary as a supplemental benefit consistent with 42 CFR section 422.102. The Plan says that you received these services from a Medicare opt out provider. The Plan verified with the provider that there was not a private contract between you and the provider regarding your financial responsibility for these services. There was no notice provided in the EOC that services with an opt out provider would not be covered for supplemental dental benefits. Therefore, we decided that the Plan has to pay for the panoramic x-ray (D0330), two surgical extractions (D7210 x2), first 15 minutes of deep sedation/general anesthesia (D9222), and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223).
We also decided that the Plan does not have to pay for the two additional surgical extractions (D7210 x2), simple extraction (D7140), and therapeutic parenteral drug (D9610).
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 therapeutic parenteral drug is not among those covered under this benefit. The contract says that extractions are limited to two procedures per calendar year. The record shows that you received four surgical extractions between October 20, 2020, and October 26, 2020, two of which we have decided that the Plan must cover, and your extractions benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the two additional surgical extractions (D7210 x2), simple extraction (D7140), and therapeutic parenteral drug (D9610).
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.