Appeal type: Practitioner Services
Decision: Favorable

We decided the Plan has to pay for anesthesia services provided during dental surgery on January 26, 2021.
You asked the Plan to pay for anesthesia services. You say your surgeon felt that it was necessary for your
dental surgery to be performed in an inpatient setting due to your medical history. The Plan denied your
request. The Plan says that these services are not covered by your medical plan. We upheld the Plan's
decision to deny payment of the anesthesia services. After research of an additional related case, we
decided to reopen this appeal.
We found that there are two categories of dental services that are excluded from coverage: a primary
service (regardless of care or complexity) provided for the care, treatment, removal or replacement of teeth or
structures directly supporting the teeth, and a secondary service that is related to the or structures directly
supporting the teeth unless it is a necessary part of a covered primary service that is required to treat a non-dental
condition (such as a tumor removal) and is performed at the same time as the primary service by the
same provider.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
When a contracted provider furnishes a service or refers an enrollee for a service that an enrollee reasonably
believes is a plan-covered service, the enrollee cannot be financially liable for more than the applicable cost-sharing
for that service.
Plans are expected to work with their contracted providers to ensure that clear processes are in place and
providers are educated about those processes. The Plan follows these rules.
You required tooth extractions and your dental benefits cover the surgical removal of teeth. You saw a Plan contracted
oral surgeon, who reviewed your x-rays and medical history. Your provider referred you to receive
the dental care at a Plan-contracted hospital setting, because they felt this was medically necessary due to your
history and x-rays. The file does not indicate that either the initial provider who referred the services or the
hospital that performed the services informed you that the surgical extractions would not be covered in a
medical setting. The Plan and its contracted providers have a responsibility to ensure that enrollees know what
services will and will not be covered. Your oral surgeon informed you that services were medically necessary
and needed to be performed in a hospital, and with that information, you could not have reasonably expected
hospital bills from a Plan contracted provider to not be covered. The Plan or Plan provider must, at minimum,
let you know before receiving services exactly which services will or will not be covered.
There is no indication that either provider requested prior authorization for these services, which included the
anesthesia services from a non-plan provider. The records do not show that the Plan provided notice that the
anesthesia services provided during the dental surgery would not be covered. According to your Plan's
contract, anesthesia is listed as covered by the Plan in certain circumstances. You were not given notice that
anesthesia during what you believed to be a medical surgery would not be covered. Under Medicare rules, this
means the anesthesia provided during this dental surgery is considered approved by the Plan. This decision is
not about whether the services are covered benefits of Medicare, but about Plan and contracted provider
responsibility to let you know the costs of non-covered services with contracted providers, before receiving the
services and incurring large medical debt. Therefore, we have now decided that the Plan must pay for the
anesthesia services provided on January 26, 2021.