Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay up to the $750 allowance for the comprehensive oral evaluation, panoramic
x-ray, bitewing x-rays, and resin-based composites. We decided that the Plan does not have to pay more than
the $750 allowance for the comprehensive oral evaluation, panoramic x-ray, bitewing x-rays, and resin-based
composites.
You asked the Plan to pay for the comprehensive oral evaluation, panoramic x-ray, bitewing x-rays, and resinbased
composites. You say that you were given the name of this provider by a Plan representative. You also
say that you were not advised that this provider had opted out of Medicare. The Plan says that the treating
provider had opted out of Medicare at the time these services were rendered. The Plan also says that you were
given the name of this provider and advised that your plan does not limit the use of providers (in-network or
out-of-network status).
We decided that the Plan has to pay up to the $750 allowance for the comprehensive oral evaluation,
panoramic x-ray, bitewing x-rays, and resin-based composites.
The Plan follows Medicare rules. Medicare rules say that the 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 Plan denied this request for the services being rendered by a Medicare opt out provider. The 2020 EOC
states that you have a $750 combined allowance for supplemental and comprehensive dental services every
year. The contract does not clearly state that dental services received by a Medicare opt out provider are not
covered. You reasonably believed that these services would be covered up to the $750 annual allowance.
Therefore, we decided that the Plan has to pay up to the $750 allowance for the comprehensive oral evaluation,
panoramic x-ray, bitewing x-rays, and resin-based composites.
We also decided that the Plan does not have to pay more than the $750 allowance for the comprehensive
oral evaluation, panoramic x-ray, bitewing x-rays, 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, the Plan offers a $750 combined
allowance for supplemental preventive and comprehensive services every year. The contract says that you are
responsible for any amount over and above the allowance limit. Therefore, we decided that the Plan does not
have to pay more than the $750 allowance for the comprehensive oral evaluation, panoramic x-ray, bitewing xrays,
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.