Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the preventative cleaning and evaluation (D1110, D0120) provided on November 19, 2020 and pay for the problem-focused oral evaluation (D0140) and resin filling (D2393) provided on December 3, 2020.
You asked the Plan to waive the copayment for the services provided on November 19, 2020 or pay for the dental services provided on December 3, 2020. You say that the Plan incorrectly denied these services and there should be no cost to you for the initial preventative services. The Plan denied your request. The Plan says there is a $50 copayment for dental office visits. Only one evaluation of any type is covered per year, and resin fillings can only be covered on the front teeth and outward facing surfaces of the bicuspids. You did not have your resin filling on an eligible tooth, but the Plan agreed to make a partial payment that would be allowed for a silver filling on the same tooth.
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 pay a $50 copayment for a dental office visit, regardless of the type of services received.
You have been asked to pay a $50 copayment for the preventative dental services (a cleaning, x-rays, and a periodic oral evaluation) provided on November 19, 2020. Preventative and diagnostic dental services require a $50 copayment for the office visit provided at the time of services. There is no additional copayment or coinsurance for the individual services provided. This means that you have been asked to pay the correct amount 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 waive the copayment for the preventative dental services (D1110, D0120) provided on November 19, 2020.
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 one evaluation per year and can cover amalgam (silver) fillings on any teeth. Resin fillings can be covered on anterior teeth and the buccal surface of bicuspids only.
The Plan can cover an evaluation once per year. This evaluation can be a periodic, limited, problem-focused, or comprehensive exam. Documentation was provided to show that you had a periodic evaluation (D0120) on November 19, 2020 which was covered by the Plan. Therefore, when you had your problem-focused evaluation (D0140) on December 3, 2020, you had already exhausted your once-per-year benefit for oral evaluations. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested problem-focused oral evaluation exceeded the limit of one evaluation per year. Therefore, we decided that the Plan does not have to pay for the problem-focused oral evaluation (D0140) provided on December 3, 2020.
The Plan can cover amalgam fillings on any teeth and resin fillings on anterior teeth and the buccal surface of bicuspids (the front teeth). You had a resin filling done on a tooth/surface where resin restorations are excluded from coverage by the Plan. The Plan acknowledges that a filling was necessary. The Plan cannot cover a resin filling for this tooth as provided, however the Plan has offered partial coverage of this service under the amalgam (silver) filling price, as a silver filling can be covered for this tooth. You are responsible for the difference in price between the resin filling that was provided and the silver filling that the Plan can cover.
Fillings fall into the Basic Restorative services dental category, which requires a $50 deductible, a $50 office visit copayment and 50% coinsurance for individual services. At the time of service, you had not met your $50 deductible for restorative services.
The Plan's allowed amount for a silver filling is $176. You must meet your $50 deductible before the Plan will pay for any restoration services. ($176 allowed amount - $50 deductible = $126). Individual services in the Basic Restorative dental category also require 50% coinsurance. This leaves you responsible for $63 after your deductible ($126 amount remaining x 50% coinsurance = $63). Then you are responsible for a $50 copayment for a dental office visit, which was applied to this service as it was the only covered service on the date in question. You are also responsible for the difference between what the provider billed for the resin filling ($260) and the Plan's allowed cost for a silver filling ($176) ($260 - $176 = $84). Your total bill was correctly applied as $247 for this service ($50 deductible + $63 coinsurance + $50 office copayment + $84 difference in cost between covered silver filling and excluded resin filling = $247).
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested resin composite filling does not meet the Plan's rules for coverage. The Plan has offered to pay part of the cost up to the price of a silver filling, which does meet the Plan's rules. You have been asked to pay the correct amount for a silver filling 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 cover the cost of a resin filling or waive the cost-share for the filling (D2160) provided on December 3, 2020.