Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350), adjunctive pre-diagnostic test (D0431), topical application of fluoride varnish (D1206), oral hygiene instructions (D1330), two core buildups, including any pins when required (D2950 x2), four periodontal scalings and root planings (D4342 x4), four gingival irrigations (D4921 x4), four periodontal procedures (D4999 x4), drugs or medicaments dispensed in the office for home use (D9630), complete series of intraoral x-rays (D0210), additional intraoral periapical x-ray (D0230), and two crowns (D2740 x2) provided on April 6, 2021, and April 8, 2021.
You asked the Plan to pay for the 2D oral/facial photographic image, adjunctive pre-diagnostic test, topical application of fluoride varnish, oral hygiene instructions, core buildups, including any pins when required, scalings and planings, gingival irrigations, periodontal procedures, drugs or medicaments, complete series of intraoral x-rays, additional intraoral periapical x-ray, and crowns. You say that you cannot afford to pay for these bills. You also say that you feel the dentist took advantage of you by rendering unnecessary services. The Plan denied your request. The Plan says the 2D oral/facial photographic image, adjunctive pre-diagnostic test, topical application of fluoride varnish, oral hygiene instructions, core buildups, including any pins when required, scalings and planings, gingival irrigations, periodontal procedures, and drugs or medicaments are not covered benefits. The Plan also says that your benefits for the complete series of intraoral x-rays, additional intraoral periapical x-ray, and crowns have been satisfied and the frequency limitation has been exceeded.
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 2D oral/facial photographic image (D0350), adjunctive pre-diagnostic test (D0431), topical application of fluoride varnish (D1206), oral hygiene instructions (D1330), core buildup, including any pins when required (D2950), periodontal scaling and root planing (D4342), gingival irrigation (D4921), unspecified periodontal procedure (D4999), and drugs or medicaments dispensed in the office for home use (D9630) are not among those covered under this benefit. The Plan contract says that full mouth or panoramic x-rays are limited to one procedure code every five years. The record shows that you received a panoramic x-ray on April 6, 2021 and your full mouth or panoramic x-rays benefit has been exhausted. The Plan contract also says that intraoral x-rays are limited to one procedure code per calendar year and crowns are limited to one procedure code per calendar year, and you are responsible for a 70% coinsurance. The record shows that you received two crowns on April 8, 2021, one of which was covered by the Plan at a 30% coinsurance, and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350), adjunctive pre-diagnostic test (D0431), topical application of fluoride varnish (D1206), oral hygiene instructions (D1330), two core buildups, including any pins when required (D2950 x2), four periodontal scalings and root planings (D4342 x4), four gingival irrigations (D4921 x4), four periodontal procedures (D4999 x4), drugs or medicaments dispensed in the office for home use (D9630), complete series of intraoral x-rays (D0210), additional intraoral periapical x-ray (D0230), and two crowns (D2740 x2) provided on April 6, 2021, and April 8, 2021.