Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for a limited oral evaluation (D0140) received on March 18, 2020, and for 
bitewing x-rays (D0274) received on June 16, 2020. 
 
We decided that the Plan does not have to pay for a dental core buildup (D2950) and a periapical x-ray 
(D0220) received on March 18, 2020; a limited oral evaluation (D0140) received on March 24, 2020; and a 
bone graft procedure (D7953) performed on March 30, 2020. 
 
We decided that the Plan does not have to waive the coinsurance for an extraction (D7210) performed on 
March 30, 2020, and for two retainer crowns (D6740 x 2) and a pontic (D6245) received on May 19, 2020. 
 
You asked the Plan to pay for a dental core buildup (D2950) and a periapical x-ray (D0220) received on March 
18, 2020; a limited oral evaluation (D0140) received on March 18 and March 24, 2020; a bone graft procedure 
(D7953) performed on March 30, 2020; and bitewing x-rays (D0274) received on June 16, 2020. You also 
asked the Plan to waive the coinsurance for an extraction (D7210) performed on March 30, 2020, and for two 
retainer crowns (D6740 x 2) and a pontic (D6245) received on May 19, 2020. You say that you paid out of 
pocket for items/services that you could not use or were deficient. The Plan says that these claims were 
processed correctly. 
 
We decided that the Plan has to pay for a limited oral evaluation (D0140) received on March 18, 2020, 
and for bitewing x-rays (D0274) received on June 16, 2020.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request for a limited oral evaluation and bitewing x-rays. The Plan contract says that 
enrollees are eligible for an oral evaluation every six months and for bitewing x-rays once every year. The Plan 
has not provided documentation to support that a prior oral evaluation was provided fewer than six months 
before the visit on March 18, 2020, or that prior bitewing x-rays were received less than a year before the visit 
on June 16, 2020. Therefore, we decided that the Plan has to pay for a limited oral evaluation (D0140) received 
on March 18, 2020, and for bitewing x-rays (D0274) received on June 16, 2020. 
 
We also decided that the Plan does not have to pay for a dental core buildup (D2950) and a periapical x-
ray (D0220) received on March 18, 2020, and a bone graft procedure (D7953) performed on March 30, 
2020. 
 
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, a dental core buildup, a periapical x-
ray, and a bone graft procedure are not among the items/services covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for a dental core buildup (D2950) and a periapical x-ray (D0220) 
received on March 18, 2020, and a bone graft procedure (D7953) performed on March 30, 2020. 
 
We also decided that the Plan does not have to pay for a limited oral evaluation (D0140) received on 
March 24, 2020. 
 
The Plan contract says that enrollees are eligible for coverage of an oral evaluation every six months. An oral 
evaluation was provided on March 18, 2020, fewer than twelve months prior to the visit on March 24, 2020. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) received on 
March 24, 2020. 
 
We decided that the Plan does not have to waive the coinsurance for an extraction (D7210) performed on 
March 30, 2020, and for two retainer crowns (D6740 x 2) and a pontic (D6245) received on May 19, 2020. 
 
The rules 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 for comprehensive dental services such as restorative services, endodontics, periodontics, and 
extractions.  
 
You have been asked to pay $65.62 coinsurance, or 50% of the Medicare-allowed amount of $131.25, for an 
extraction, two payments of $299.62 coinsurance, or 50% of the Medicare-allowed amount of $599.25, for two 
retainer crowns, and $246.75 coinsurance, or 50% of the Medicare-allowed amount of $493.50, for a pontic. 
An extraction, retainer crowns, and a pontic fall within the Dental services? benefit category. 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 waive the coinsurance for an extraction (D7210) performed on March 30, 2020, and for two 
retainer crowns (D6740 x 2) and a pontic (D6245) received on May 19, 2020. 
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review. 
 
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.