Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay in full for the one periodic oral evaluation, one first intraoral periapical x-ray, and bitewing x-rays. We decided that the Plan does not have to pay for the two periodontal maintenance services, additional periodic oral evaluation, additional first intraoral periapical x-ray, crown, and resin-based composites.
You asked the Plan to pay for the two periodontal maintenance services, two periodic oral evaluations, two first intraoral periapical x-rays, bitewing x-rays, two anterior resin-based composites, and posterior resin-based composite. You say that the provider would not send in the claims to the insurance company. You also say that you would like to be reimbursed for these services. The Plan says that periodontal maintenance is not a covered benefit. The Plan says that your benefits for the additional periodic oral evaluation and additional two resin-based composites have been satisfied and the frequency limitations had been exceeded. The Plan also says that these services were rendered by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
We decided that the Plan has to pay in full for the one periodic oral evaluation, one first intraoral periapical x-ray, and bitewing x-rays provided in 2019.
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 2019 EOC says that periodic oral exams, bitewing x-rays, and intraoral x-rays are covered services, are each limited to one procedure per calendar year, and you are responsible for a 0% coinsurance when the services are received OON. The Plan contract does not clearly say that you will be responsible for the difference between the amount billed by the provider and the allowable amount paid by the Plan, nor does the 2019 contract say that you can expect to pay more for covered services provided OON. You reasonably believed during the 2019 plan year that the first periodic oral exam, bitewing x-rays, and first intraoral x-ray would be covered in full. Therefore, we decided that the Plan has to pay in full for the one periodic oral evaluation, one first intraoral periapical x-ray, and bitewing x-rays.
We also decided that the Plan does not have to pay for the two periodontal maintenance services, additional periodic oral evaluation, additional first intraoral periapical x-ray, crown, and resin-based composites.
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, periodontal maintenance is not among those covered under this benefit. The contract says that periodic oral exams and intraoral x-rays are each limited to one procedure per calendar year. The record shows that you received a periodic oral exam and first intraoral periapical x-ray on April 10, 2019, which were covered by the Plan, and your periodic oral exams and intraoral x-rays benefits for the 2019 plan year had been exhausted. Therefore, we decided that the Plan does not have to pay for the two periodontal maintenance services, additional periodic oral evaluation, additional first intraoral periapical x-ray, crown, and resin-based composites.
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.