Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the intraoral periapical x-rays. We decided that the Plan does not have
to pay for the diagnostic cast, custom-fabricated abutments and abutment supported porcelain/ceramic crowns.

You asked the Plan to pay for the intraoral periapical x-rays, diagnostic cast, custom-fabricated abutments and
abutment supported porcelain/ceramic crowns. You say that these services were medically necessary. The Plan
says that diagnostic casts, custom-fabricated abutments, and abutment supported porcelain/ceramic crowns are
not covered by Medicare or by the Plan's supplemental dental benefit. Additionally, because the Plan already
paid for a panoramic x-ray for the enrollee within the same year, the intraoral x-rays exceed the benefit
allowance and cannot be covered.

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 two intraoral periapical x-rays.

The Plan denied payment of the intraoral periapical x-rays (D0220 and D0230) on the basis that they had paid
for a panoramic x-ray for the enrollee within the same year. Because of this, the Plan states that the enrollee is
not eligible for any other x-ray for twelve months from the date of service. However, the Plan's contract
indicates that there are two separate bundles for x-ray images. The contract states that the Plan will cover up to
six periapical (individual) x-rays or one combination of two bitewings and four periapical images every twelve
months. The contract goes on to state that the Plan will cover up to one complete set of "full mouth"
radiographs or one panoramic x-ray every thirty-six months. There is no indication that receiving one x-ray
from the twelve-month category will affect eligibility for an x-ray from the thirty-six-month category, or vice
versa. It is only clear that if the Plan has paid for a panoramic x-ray in one Plan year, the enrollee will not be
eligible for payment of a panoramic x-ray or an intraoral full mouth x-ray for thirty-six months from the date of
service.

There is no evidence that the benefit for individual x-rays was previously exhausted in the form of six
periapical (individual) images or two bitewings with four periapical images. Therefore, we decided that the
Plan has to pay for the two individual intraoral x-ray images (D0220, D0230).

We also decided that the Plan does not have to pay for diagnostic casts, custom-fabricated abutments,
and the abutment supported porcelain/ceramic crowns.

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. Therefore, we decided that the Plan does not have to pay for the
diagnostic cast (D0470), custom-fabricated abutments (D6057), and abutment supported porcelain/ceramic
crowns (D6058).

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.