Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reduce the charges for the periodic oral evaluation, first intraoral periapical x-
ray, periodontal maintenance, one amalgam, and one resin-based composite. We decided that the Plan does not 
have to pay for the two additional intraoral periapical x-rays, additional amalgam, three resin-based 
composites, and unspecified maxillofacial prosthesis.  
 
You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, two additional 
intraoral periapical x-rays, periodontal maintenance, two amalgams, four resin-based composites, and 
unspecified maxillofacial prosthesis. The Plan says that the claims for these services have been processed 
correctly. 
 
We decided that the Plan has to reduce the charges for the periodic oral evaluation, first intraoral 
periapical x-ray, periodontal maintenance, one amalgam, and one resin-based composite.  
 
The Plan follows Medicare rules. Medicare rules say that the health 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 EOC does not clearly state that you may pay more when receiving dental services out-of-network. You 
reasonably believed that these services would be covered, even when being seen out-of-network. Therefore, we 
decided that the Plan has to reduce the charges for the periodic oral evaluation, first intraoral periapical x-ray, 
periodontal maintenance, one amalgam, and one resin-based composite.  
 
We also decided that the Plan does not have to pay for the two additional intraoral periapical x-rays, 
additional amalgam, three resin-based composites, and unspecified maxillofacial prosthesis. 
 
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 unspecified maxillofacial 
prosthesis is not among those covered under this benefit. The Plan contract says that intraoral x-rays are limited 
to one procedure per calendar, and restorations (fillings) are limited to two procedures per calendar year. The 
record shows that you received a first intraoral periapical x-ray on July 12, 2020, and your intraoral x-rays 
benefit had been exhausted. The record also shows that you received an amalgam and a resin-based composite 
on August 20, 2020, and your restorations benefit had been exhausted. Therefore, we decided that the Plan does 
not have to pay for the two additional intraoral periapical x-rays, additional amalgam, three resin-based 
composites, and unspecified maxillofacial prosthesis. 
 
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.