Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to reimburse up to the maximum benefit for the crown. We decided that the Plan
does not have to reimburse up to the maximum benefit for the core build up.

You asked the Plan to reimburse up to the maximum benefit for the crown. You say that there were no dentists
in your area that would accept your benefits. You say that you were advised you should fill out a
reimbursement form to get payment for the services as long as they are not cosmetic. You say that the claim
was sent to medical instead of dental. You say that the claim was denied due to the provider opting out of
Medicare. You also say that your wife received services from the same provider and her claim was paid. The Plan says that the provider in this case has opted out of Medicare. The Plan also says that payment cannot be
made for services you receive from a provider who has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. 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 reimburse up to the maximum benefit for the crown.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. We find that the Plan did not provide a valid denial rationale. Specifically,
Medicare opt out status means that the provider has opted out of reimbursement for Medicare-covered services.
This cannot be applied to dental services that are covered under a supplemental benefit. The Evidence of
Coverage does not clearly state that services you receive from a dental provider who has opted out of Medicare
are not covered. Instead, it states that you can use any licensed dental provider who is eligible to participate in
Medicare. Despite the opt out status, this provider is still eligible to participate in Medicare. As such, we find
that the Plan's denial is not supported. Therefore, we decided that the Plan has to reimburse up to the maximum
benefit for the crown.


We also decided that the Plan does not have to reimburse up to the maximum benefit for the core build
up.

Though the Plan offers a dental benefit in excess of Medicare coverage, core build up is not among those
covered under this benefit. The Customer Handbook clearly states that if a dental item or service is not listed in
the benefit chart or listed with NC, then it is not covered. Therefore, we decided that the Plan does not have to
reimburse up to the maximum benefit for the core build up.

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.