Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), intraoral x-rays (D0220, D0230), and an extraction (D7140) provided on February 22, 2021, by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you do not understand why the Plan is paying so little on this bill or how your benefits could be exceeded as you rarely use them. The Plan denied your request. The Plan says these claims processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 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 periodic, periodontal, and comprehensive oral evaluations. The Plan can also cover one procedure code for intraoral x-rays per calendar year with 50% coinsurance when received from an out-of-network provider. The Plan can cover up to two extractions per calendar year, and you must pay 55% coinsurance when you receive these services out-of-network. You may also be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider.
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is not among those covered under this benefit and two of the three intraoral x-ray images exceed what is covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and two of the intraoral x-rays (D0220, D0230) provided on February 22, 2021.
Documentation shows that the Plan paid $8 for one of the intraoral x-ray images. The provider billed the Plan $54, but the Plan's maximum allowed amount (this amount is the same regardless of whether the provider is in-network or out-of-network) is $16. Because this x-ray image was provided out-of-network, you are responsible for 50% of this cost ($16 x 50% coinsurance = $8). You may also be billed by the provider for any amount greater than the payment made by the Plan to the provider. ($54 - $16 = $38). This means that you have been asked to pay the correct amount for the covered intraoral x-ray based on your contract with the Plan.
Documentation also shows that the Plan paid $37.35 for the extraction. The provider billed $241 for this service, and the Plan's maximum allowed amount is $83. Because this service was provided out-of-network, you are responsible for 55% of the Plan's allowed amount ($83 x 55% coinsurance = $45.65) and you may also be billed for any amount greater than the payment made by the Plan to the provider ($241 - $83 = $158). 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 provide any additional payment for the intraoral x-ray image (D0220) and extraction (D7140) provided on February 22, 2021.