Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the x-ray, crowns and core buildup procedures. We decided that the
Plan does not have to pay for the unspecified preventative procedure.
You asked the Plan to pay for the dental services. You say that you were told by your provider that these
services would be covered in full. The Plan says that x-rays are only covered once every twelve months, and
you had a previous dental x-ray less than twelve months before the date in question. The Plan also says that an
unspecified preventative procedure is not covered by your dental benefit, and you have a $4,000 benefit limit
for comprehensive dental services. The crowns and core buildup services were partly covered; however, you
met the annual limit and are responsible for the excess charges.
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. 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.
We decided that the Plan has to pay for the three crowns, three core buildups, and x-ray.
The Plan denied the x-ray on the basis that you had previously received an x-ray within twelve months of the
date in question. The Plan denied part of the payment for the crowns and core buildup procedures because they
say that you had met your $4,000 annual benefit limit for supplemental comprehensive dental services.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The case file did not contain information regarding a previous x-ray that was
paid for by the Plan within twelve months of October 19, 2020. The case file also did not include evidence that
the Plan had paid out your full $4,000 in comprehensive dental care. The dental claim detail included in the file
also shows that the full approved amount for the cost of services provided on October 19, 2020, was $1,490.
The provider in question is indicated as a Plan-contracted provider and the total approved bill of these services
is less than $4,000. Information regarding Plan payments for prior services in 2020 were not included in the
case file, and the specific services were not listed with payment, so we cannot confirm that any previous bills in
2020 were solely for comprehensive services. The Plan has failed to forward sufficient information explaining
why payment was denied for these services.
There is no evidence that you had a previous dental x-ray within twelve months of the date in question or that
you had met your $4,000 annual comprehensive dental limit. These services are covered services according to
the Plan's contract. Therefore, we decided that the Plan has to pay for the bitewing x-ray (D0270), crowns
(D2740) and core buildups (D2950) provided on October 19, 2020.
We also decided that the Plan does not have to pay for the unspecified preventative procedure.
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 has to pay for the unspecified
preventative procedure (D1999) provided on October 19, 2020.
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.