Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the panoramic x-ray (D0330), tooth extraction (D7210) and deep sedation/general anesthesia (D9222, D9223). We decided that the Plan does not have to pay for the surgical placement of implant body (D6010), unspecified preventative procedure (D1999), bone graft for implant placement (D6104), diagnostic consultation (D9310) and therapeutic parenteral drugs (D9612).

You asked the Plan to pay for several dental services. You say that you chose an in-network provider and facility to have these procedures done. Two providers were present. You were under general anesthesia while the procedures were performed so you did not know who did the actual dental work, but you assumed that the in-network provider did the work. You had a cost estimate done and expected the predetermination to be honored by the Plan. The Plan says that this provider who submitted the claims has chosen to opt-out of Medicare, which means that they are not permitted to send claims to Medicare or Medicare Advantage plans, except for urgent or emergent services. The Plan cannot make payments to opt-out providers.

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 panoramic x-ray (D0330), tooth extraction (D7210) and deep sedation/general anesthesia (D9222, D9223).

The Plan offers coverage for these services; however, they were denied by the Plan in this case because they were received from a provider who has chosen to opt-out of Medicare. Normally, providers who have opted-out of Medicare are unable to receive payments from Medicare plans for medical services. However, the Centers for Medicare and Medicaid Services (CMS) has stated that opt-out provisions do not apply to supplemental benefits unless the Plan specifically states this limitation in the contract. Dental services are not covered by Medicare and are instead covered by a supplemental benefit offered by the Plan. Opt-out rules do not prevent a provider from being paid for non-Medicare covered benefits.

The Plan's contract states that in-network and out-of-network providers can be used. There is no statement in the contract that includes or excludes the use of dental providers who have chosen to opt-out of Original Medicare. Therefore, we decided that the Plan has to pay for the panoramic x-ray (D0330), tooth extraction (D7210) and deep sedation/general anesthesia (D9222, D9223).

Please note that the address of this facility and the provider who rendered services are not listed on the in-network provider sheet that was included in your appeal, and the Plan may reimburse these services at the out-of-network rate.

We also decided that the Plan does not have to pay for the surgical placement of implant body (D6010), unspecified preventative procedure (D1999), bone graft for implant placement (D6104), diagnostic consultation (D9310) and therapeutic parenteral drugs (D9612).

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, regardless of who provides the services. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body (D6010), unspecified preventative procedure (D1999), bone graft for implant placement (D6104), diagnostic consultation (D9310) and therapeutic parenteral drugs (D9612).

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.