Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to hold you harmless for the office visit for observation. We also decided that the Plan does not have to pay for the oral hygiene instructions, scaling and root planing, unspecified procedures and local anesthesia.

You asked the Plan to pay for the dental services. You say that this cleaning was necessary for your upcoming heart surgery. You believed the cleaning would be covered and you had a poor experience at the provider's office and raised several concerns regarding the quality of care and treatment by the office staff. The Plan says that these services are not covered by your dental benefits. The Plan has also opened a separate grievance to address your quality of care concerns.

We decided that the Plan has to hold you harmless for the office visit for observation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed.

In this case, the CPT Code Manual definition of code D9430 is an office visit for observation (during regularly scheduled hours) with no other services performed for the enrollee.

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the code at issue was billed correctly. Our reviewer says that the office visit for observation (D9430) is not supported in this case. The record indicates that on the date in question, the provider billed for other services. Therefore, the elements of the coverage criteria are not satisfied for this service, and it cannot be recommended as billed.

An office visit for observation with no other services performed is not covered by the Plan's dental benefit. The Plan does not have to pay for this service, but they also cannot ask you to pay for a service that is not supported as billed. Based on this information, we decided that the Plan has to hold you harmless for the office visit for observation with no other services performed (D9430) provided on April 22, 2021.

We also decided that the Plan does not have to pay for the oral hygiene instructions, scaling and root planing, unspecified procedures and local anesthesia.

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 oral hygiene instructions (D1330), periodontal scaling and root planing (D4341, D4342), unspecified periodontal procedures (D4999) and local anesthesia in conjunction with operative or surgical procedures (D9215) provided on April 22, 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.