Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to hold you harmless for dental surgery, hospital services and supplies performed on January 26, 2021.

You asked the Plan to hold you harmless for dental surgery, hospital services and supplies. You say that your surgeon felt that it was necessary for this surgery to be performed in an inpatient setting, as an outpatient setting posed too much risk with your medical history. The Plan denied your request. The Plan says that these services are not covered by your medical plan. There are two categories of dental services that are excluded from coverage: a primary service (regardless of care or complexity) provided for the care, treatment, removal or replacement of teeth or structures directly supporting the teeth, and a secondary service that is related to the or structures directly supporting the teeth unless it is a necessary part of a covered primary service that is required to treat a non-dental condition (such as a tumor removal) and is performed at the same time as the primary service by the same provider.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.

When a contracted provider furnishes a service or refers an enrollee for a service that an enrollee reasonably believes is a plan-covered service, the enrollee cannot be financially liable for more than the applicable cost-sharing for that service. Plans are expected to work with their contracted providers to ensure that clear processes are in place and providers are educated about those processes. The Plan follows these rules.

You required tooth extractions and your dental benefits cover the surgical removal of teeth. You saw a Plan-contracted oral surgeon, who reviewed your x-rays and medical history. Your provider referred you to receive the dental care at a Plan-contracted hospital setting, because they felt this was medically necessary due to your history and x-rays. The file does not indicate that either the initial provider who referred the services or the hospital that performed the services informed you that the surgical extractions would not be covered in a medical setting. The Plan and its contracted providers have a responsibility to ensure that enrollees know what services will and will not be covered. Your oral surgeon informed you that services were medically necessary and needed to be performed in a hospital, and with that information, you could not have reasonably expected hospital bills from a Plan contracted provider to not be covered. The Plan or Plan provider must, at minimum, let you know before receiving services exactly which services will or will not be covered.

There is no indication that either provider requested prior authorization for these services, and the file does not show that the Plan provided notice that the dental surgery, hospital services and supplies would not be covered. According to your Plan's contract, surgical tooth extractions are listed as covered by the Plan in certain circumstances, and you were not provided with the information that they are not covered in an inpatient setting, nor were you issued a denial. Under Medicare rules, this means the dental surgery and supplies are considered approved by the Plan. This decision is not about whether the services are covered benefits of Medicare, but about Plan and contracted provider responsibility to let you know the costs of non-covered services with contracted providers, before receiving the services and incurring large medical debt. Therefore, we decided that the Plan has to hold you harmless for dental surgery, hospital services and supplies performed by contracted providers on January 26, 2021.

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.