Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crowns (D2740), fillings (D2392, D2393), and core buildup procedures (D2950) provided on December 17, 2020, to December 28, 2020.

You asked the Plan to pay for the dental services. You say that these services were denied in error because the system thinks you have already had a crown on the requested teeth, and this issue should be fixed. You say you should not have to pay anything for these services. The Plan denied your request. The Plan says they are reviewing the issue with the previous claim in a separate case; however, the crowns and fillings provided in December 2020 were processed correctly. You are covered for up to two crown procedures per calendar year with 70% coinsurance, and two fillings per year with 50% coinsurance when received from an in-network provider.

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. The Plan can cover up to two crown procedures per calendar year and two filling procedures per calendar year.

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 or are requested in a frequency that exceeds what is covered by the benefit. A core buildup is not listed as a covered service under the contract, and documentation shows that the Plan has paid for two fillings and two crowns for you on December 17, 2020. Therefore, we decided that the Plan does not have to pay for the additional porcelain/ceramic crowns (D2740), fillings (D2392, D2393), and the core buildup procedures (D2950) provided on December 17, 2020, to December 28, 2020.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must 70% coinsurance for crowns received from an in-network provider and 50% coinsurance for restorations/fillings received from an in-network provider.

You have been asked to pay a total of $1,204 for the two crowns provided on December 17, 2020. The total amount billed by the provider was $2,250, but the Plan's maximum allowed amount for both crowns was $1,720. You are responsible for 70% coinsurance for crowns received from an in-network provider. ($1,720 x 70% coinsurance = $1,204). This means you have been asked to pay the correct amount for the crowns based on your contract with the Plan.

You have been asked to pay a total of $158 for the two fillings provided on December 17, 2020. The total amount billed by the provider was $614, but the Plan's maximum allowed amount for both fillings was $316. You are responsible for 50% coinsurance for fillings received from an in-network provider. ($316 x 50% coinsurance = $158). This means you have been asked to pay the correct amount for the fillings based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay any additional amount for the covered porcelain/ceramic crowns (D2740) and fillings (D2392) provided on December 17, 2020.