Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay a 55% coinsurance of the billed amount up to the $1,000 allowance for the problem focused limited oral evaluation, crown, prefabricated post and core, endodontic therapy, inhalation of nitrous oxide/analgesia, and bitewing x-ray. We decided that the Plan does not have to pay more than the $1,000 allowance for the problem focused limited oral evaluation, crown, prefabricated post and core, endodontic therapy, inhalation of nitrous oxide/analgesia, and bitewing x-ray.
You asked the Plan to pay more for the problem focused limited oral evaluation, crown, prefabricated post and core, endodontic therapy, inhalation of nitrous oxide/analgesia, and bitewing x-ray. You say that when you were in Arizona you went to the dentist and received a crown, but it kept coming off. You also say that when you got back to Kansas City you got the crown fixed but the claim was denied. The Plan says that the dental services you received were paid in accordance with your benefit plan. The Plan also says that OON providers can bill for services using their fee schedule because they are not contractually obligated.
We decided that the Plan has to a 55% coinsurance of the billed amount up to the $1,000 allowance for the problem focused limited oral evaluation, crown, prefabricated post and core, endodontic therapy, inhalation of nitrous oxide/analgesia, and bitewing x-ray
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. The 2021 EOC states that the Plan is responsible for a 55% coinsurance, and also offers a $1,000 dental allowance per year. The EOC does not clearly state that the Plan will only pay a 55% coinsurance of the allowed amount, nor does the EOC clarify that you may be billed more by an OON provider. You reasonably believed these services would be covered by the Plan at a 55% coinsurance up to your annual allowance of $1,000. Therefore, we decided that the Plan has to pay a 55% coinsurance of the billed amount up to the $1,000 allowance for the problem focused limited oral evaluation, crown, prefabricated post and core, endodontic therapy, inhalation of nitrous oxide/analgesia, and bitewing x-ray
We also decided that the Plan does not have to pay more than the $1,000 allowance for the problem focused limited oral evaluation, crown, prefabricated post and core, endodontic therapy, inhalation of nitrous oxide/analgesia, and bitewing x-ray.
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, you are responsible for a 45% coinsurance for dental services received OON, plus any amount that exceeds your $1,000 annual dental allowance. Therefore, we decided that the Plan does not have to pay more than the $1,000 allowance for the problem focused limited oral evaluation, crown, prefabricated post and core, endodontic therapy, inhalation of nitrous oxide/analgesia, and bitewing x-ray.
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.