Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two multiple-surface, resin-based fillings on back teeth (D2392, D2393) provided on January 7, 2021 and January 28, 2021.

You asked the Plan to pay for the resin-based fillings. You say that your dental provider informed you that they no longer perform amalgam/silver fillings. You also say that you did some research and found that amalgam fillings may have a greater health risk than the resin-based composites. The Plan denied your request. The Plan says multiple-surface resin-based fillings are not covered for the back teeth. Instead, claims for multiple-surface resin-based fillings will be processed as silver (amalgam) fillings, and you will be responsible for the difference in cost between the covered cost of a silver filling and the contracted rate (allowed amount) for the resin-based composites. These claims processed correctly.

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 Plan will process resin-based composites on multiple surfaces of posterior (back) teeth at the amalgam cost. You are responsible for the difference in cost between the contracted (allowed) rate for a resin-based composite and the amalgam rate. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Class 2 Basic Services, such as fillings. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

You have been asked to pay $79.60 for the filling provided on January 7, 2021. The allowed amount for a resin-based composite (two surfaces) is $182. The allowed amount for a two-surface amalgam filling is $128. You are responsible for the difference between these two amounts ($182 - $128 = $54). You are also responsible for 20% coinsurance for the allowed cost of the silver filling ($128 x 20% coinsurance = $25.60). Your total cost is your required coinsurance plus the difference in price between the silver and resin-based fillings ($54 + $25.60 = $79.60). This means that you have been asked to pay the correct amount based on your contract with the Plan.

You have been asked to pay $95.20 for the filling provided on January 7, 2021. The allowed amount for a resin-based composite (three surfaces) is $220. The allowed amount for a three-surface amalgam filling is $156. You are responsible for the difference in cost between these two amounts ($220 - $156 = $64). You are also responsible for 20% coinsurance for the allowed cost for the silver filling ($156 x 20% coinsurance = $31.20). Your total cost is your required coinsurance plus the difference in price between the silver and resin-based fillings ($64 + $31.20 = $95.20). This means that you have been asked to pay the correct amount based on your contract with the Plan. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the full cost of multi-surface, resin-based composites on posterior teeth is not covered under this benefit. The records show that you have been asked to pay the correct amount for these fillings 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 pay any additional amount for the two multiple-surface, resin-based fillings on back teeth (D2392, D2393) provided on January 7, 2021 and January 28, 2021.