Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the intraoral - periapical first radiographic image (D0220), the intraoral - periapical each additional radiographic image (D0230), the comprehensive oral evaluation (D0150), the prophylaxis (D1110), the periodic oral evaluation (D0120), the bitewings - four radiographic images (D0274), received March 2, 2021, and the resin-based composite - three surfaces, posterior (D2393) and the resin-based composite - three surfaces, anterior (D2332) received March 25, 2021 from the out-of-network provider.

You asked the Plan to pay an additional amount for the dental services. You say that the requested services are medically necessary, and you cannot afford the bill. The Plan denied your request. The Plan says if you see an out-of-network dentist, the coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in your area. You are responsible for the difference between the INFS and dentist's charged fees when visiting an out-of-network dentist.

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 requested payment is in excess of what is covered under this benefit.

On March 2, 2021 you received intraoral periapical radiographic images (D0220, D0230), a comprehensive oral evaluation (D0150), prophylaxis (D1110), and bitewing x-rays (D0274). The Plan agreed to cover one intraoral periapical radiographic image with 50% coinsurance. In addition, you are responsible for the difference between what was charged by the out-of-network provider and the Plan INFS. The remaining intraoral radiographic images exceed your Plan's benefit frequency limitation and are your responsibility. The Plan agreed to cover the comprehensive oral evaluation (D0150) with 50% coinsurance. In addition, you are responsible for the difference between what was charged by the out-of-network provider and the Plan INFS. The Plan cannot cover the periodic oral evaluation (D0120) as this procedure is considered equivalent to the comprehensive oral evaluation. The Plan agreed to cover the prophylaxis (D1110) with 50% coinsurance. In addition, you are responsible for the difference between what was charged by the out-of-network provider and the Plan INFS. The Plan agreed to cover the bitewing x-rays (D0274) with 50% coinsurance. In addition, you are responsible for the difference between what was charged by the out-of-network provider and the Plan INFS.

On March 25, 2021 you received six resin-based composites (D2393, D2332). The Plan agreed to cover two of these procedures, with 55% coinsurance. In addition, you are responsible for the difference between what was charged by the out-of-network provider and the Plan INFS. The remaining four resin-based composite procedures exceed your benefit frequency limitation and are your responsibility.

Therefore, we decided that the Plan does not have to pay an additional amount for the intraoral - periapical first radiographic image (D0220), the intraoral - periapical each additional radiographic image (D0230), the comprehensive oral evaluation (D0150), the prophylaxis (D1110), the periodic oral evaluation (D0120), the bitewings - four radiographic images (D0274), received March 2, 2021, and the resin-based composite - three surfaces, posterior (D2393) and the resin-based composite - three surfaces, anterior (D2332) received March 25, 2021 from the out-of-network provider.