Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay up to the $2,000 allowance for the comprehensive oral evaluation, panoramic x-ray, immediate maxillary denture, mandibular partial denture, ten extractions, and non-intravenous conscious sedation. We decided that the Plan does not have to pay more than the $2,000 allowance for the comprehensive oral evaluation, panoramic x-ray, immediate maxillary denture, mandibular partial denture, ten extractions, and non-intravenous conscious sedation.

You asked the Plan to pay for the comprehensive oral evaluation, panoramic x-ray, immediate maxillary denture, mandibular partial denture, ten extractions, and non-intravenous conscious sedation. You say that you would like to appeal these services. The Plan says that these services were rendered by an opt-out provider, and are not covered.

We decided that the Plan has to pay up to the $2,000 allowance for the comprehensive oral evaluation, panoramic x-ray, immediate maxillary denture, mandibular partial denture, ten extractions, and non-intravenous conscious sedation.

The rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. 

The record shows that the enrollee received care from a Medicare opt out provider. The contract does not clearly state that services rendered by a Medicare opt out provider would not be covered. The Plan contract says that the enrollee has an annual maximum benefit of $2,000 for preventive and comprehensive services. The enrollee reasonably believed that these services would be covered up to the $2,000 maximum benefit. Therefore, we decided that the Plan has to pay up to the $2,000 allowance for the comprehensive oral evaluation, panoramic x-ray, immediate maxillary denture, mandibular partial denture, ten extractions, and non-intravenous conscious sedation.

We also decided that the Plan does not have to pay more than the $2,000 allowance for the comprehensive oral evaluation, panoramic x-ray, immediate maxillary denture, mandibular partial denture, ten extractions, and non-intravenous conscious sedation.

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 Plan does not need to pay more than $2,000 for preventive and comprehensive dental services. Therefore, we decided that the Plan does not have to pay more than the $2,000 allowance for the comprehensive oral evaluation, panoramic x-ray, immediate maxillary denture, mandibular partial denture, ten extractions, and non-intravenous conscious sedation.

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.