Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay up to $2,000 for the four simple extractions, twelve surgical extractions, four local anesthesia in conjunction with operative or surgical procedures, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia. We decided that the Plan does not have to pay for the preventive procedure, or pay more than $2,000 for the four simple extractions, twelve surgical extractions, four local anesthesia in conjunction with operative or surgical procedures, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia.
You asked the Plan to pay for the four simple extractions, twelve surgical extractions, preventive procedure, four local anesthesia in conjunction with operative or surgical procedures, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia provided on January 22, 2021. You say that you believe these services should be covered. The Plan says that these services were rendered by a Medicare opt out provider. The Plan also says that you did not contact the Plan prior to this date of service to verify provider eligibility.
We decided that the Plan has to pay up to $2,000 for the four simple extractions, twelve surgical extractions, four local anesthesia in conjunction with operative or surgical procedures, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia.
The Plan follows Medicare rules. Medicare rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. The rules also say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the IRE. The record shows that you received care from a Medicare opt out provider. The contract does not clearly state that services rendered by a Medicare opt out provider would not be covered. You also have an annual maximum benefit of $2,000 for dental services. The financial agreement you signed with the provider does not state that this provider is an opt out provider. You reasonably believed that these services would be covered up to the $2,000 maximum benefit. Therefore, we decided that the Plan has to pay up to $2,000 for the four simple extractions, twelve surgical extractions, four local anesthesia in conjunction with operative or surgical procedures, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia.
We also decided that the Plan does not have to pay for the preventive procedure, or pay more than $2,000 for the four simple extractions, twelve surgical extractions, four local anesthesia in conjunction with operative or surgical procedures, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia.
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 unspecified preventive procedure is not among those covered under this benefit. The Plan also does not need to pay more than $2,000 for covered dental services. Therefore, we decided that the Plan does not have to pay for the preventive procedure, or pay more than $2,000 for the four simple extractions, twelve surgical extractions, four local anesthesia in conjunction with operative or surgical procedures, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia.