Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to make additional payment for the crown. We decided that the Plan does not have to make additional payment for the resin-based composite.
You asked the Plan to make additional payment for the resin-based composite and porcelain or ceramic crown. You say that you called to confirm that your dentist was in network with your Plan and were told that they were. You also say that you were told these services would be covered by the Plan. The Plan says that you are responsible for the difference between the allowed amounts.
We decided that the Plan has to make additional payment for the crown.
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 covers the crown the initial placement of crowns and onlays when teeth cannot be restored with regular filings due to fracture or decay, and you are responsible for a 50% coinsurance once the $100 deductible has been met. We looked at the file and Medicare rules. The contract does not clearly state that a porcelain or ceramic crown (D2740) would be reduced to a porcelain fused to predominantly base metal crown (D2751). The records do not show that you were informed by the dentist that you were receiving an upgrade. The rules say the Plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The Plan contract says that you are only liable for 50% coinsurance after meeting the $100 deductible. The Plan says that you must pay $450.00. Based on the Plan contract, however, you cannot be asked to pay more than $416.50. Therefore, we decided that the Plan has to reduce the cost for the porcelain or ceramic crown from $450.00 to $416.50.
We also decided that the Plan does not have to make additional payment for the resin-based composite.
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, white fillings (back teeth) are covered once every 24 months per surface, and multi-surfaces will be processed as a silver filling. You are responsible for a 50% coinsurance once the $100 deductible for Class 2 Basic Services has been met. The Plan is only required to pay for a silver filling, as noted in the EOC. The Plan processed the claim to show that they applied the remaining $81 toward your $100 deductible, and then $8 remained for you to pay a 50% coinsurance of $4. The record shows that this service was processed correctly. The contract also states that the Plan is only responsible for a 50% coinsurance of the allowed amount for crowns. You are responsible for paying $416.50 for the crown. Therefore, we decided that the Plan does not have to make additional payment for the resin-based composite, or pay more than a 50% coinsurance for the crown.
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.