Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150), intraoral - complete series of radiographic images (D0210), adjunctive pre-diagnostic test that aids in 
detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or 
biopsy procedures (D0431), resin-based composite - one surface, posterior (D2391), pulp cap - indirect 
(excluding final restoration) (D3120) and resin-based composite - three surfaces, posterior (D2393) provided 
on November 25, 2019 and December 2, 2019. 
 
You asked the Plan to pay for the dental services. You say that you are appealing your cost-share responsibility 
for the services you received. The Plan denied your request. The Plan says the claims were processed 
accordingly with your 2019 EOC benefits. 
 
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. 
 
According to your 2019 EOC, page 66 under Dental Services: What you must pay when you get these services 
it states: ?20% coinsurance of the covered plan allowance after the $100 annual deductible is met for 
restorations (fillings).?  On page 97, it states: ?If you get services that are excluded (not covered), you must pay 
for them yourself.?  Additionally, on page 98 it states, ?Procedures to alter vertical dimension (bite height 
based on the resting jaw position) including but not limited to, occlusal (bite) guards and periodontal splinting 
appliances (appliances used to splint or adhere multiple teeth together), and restorations (filings, crowns, 
bridges, etc.,) are not covered.? 
 
Records show that the claim for date of service November 25, 2019, procedure code D0150 (Comprehensive 
Oral Evaluation) was billed to your another Dental plan and then billed to this dental plan for a coordination of 
benefits. The amount billed was $124.00. The fee schedule allowed amount was $55.00. Your another Dental 
plan paid $49.00 based on the documentation provided by this dental plan, resulting in a $6 balance which was 
paid by this dental plan ($55.00 - $49.00).  Date of service December 2, 2019 for procedure codes D2391 
(Resin-based composite ? one surface posterior), D3120 (Pulp Cap ? indirect tooth #31), D2393 (Resin-Based 
Composite ? three surfaces posterior) and D3120 (Pulp Cap ? indirect tooth #32). D3120 is not a covered 
service under your plan. D2391 satisfied your $100.00 annual deductible. The amount billed for D2393 is 
$184.00. Your other Dental paid $114.40 and this dental plan paid $32.80 (80% of the allowed amount) leaving 
you a  balance due of $36.80. Therefore, we decided that the Plan does not have to pay for comprehensive oral 
evaluation - new or established patient (D0150), intraoral - complete series of radiographic images (D0210), 
adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and 
malignant lesions, not to include cytology or biopsy procedures (D0431), resin-based composite - one surface, 
posterior (D2391), pulp cap - indirect (excluding final restoration) (D3120) and resin-based composite - three 
surfaces, posterior (D2393) provided on November 25, 2019 and December 2, 2019.