Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay forthe periodontal scalings and root planings of the upper left, lower left, and lower right quadrants. We decided that the Plan does not have to pay forthe endodontic therapy, miscellaneous dental service, extraction of an erupted tooth or exposed root, and two additional extractions of an erupted tooth requiring removal of bone and/or sectioning of tooth. You asked the Plan to pay forthe periodontal scalings and root planings of the upper left, lower left, and lower right quadrants, endodontic therapy, miscellaneous dental service, extraction of an erupted tooth or exposed root, and two additional extractions of an erupted tooth requiring removal of bone and/or sectioning of tooth. You say that these services were medically necessary.The Plan says that the enrollee's benefit includes only one periodontal scaling and root planing per year and this benefit had been exhausted. The Plan says that endodontic therapy and miscellaneous dental service are not covered benefits. The Plan also says that benefits for extractions had been satisfied and the frequency limitation had been exceeded.We decided that the Planhas to pay forthe periodontal scalings and root planings of the upper left, lower left, and lower right quadrants. 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 scaling and root planings and are limited to one procedure per calendar year, per quadrant.We looked at the file and Medicare rules. The EOC states that scaling and root planings are limited to one procedure per calendar year, per quadrant. The record shows that the Plan paid for one periodontal scaling and root planing procedure of the upper right quadrant only. The documentation does not show that this benefithad been exhausted for the periodontal scalings and root planings of the upper left, lower left, and lower right quadrants. Based on this information, we decided that the Plan's rules for coverage of the periodontal scalings and root planings of the upperleft, lower left, and lower right quadrants have been met.Therefore, we decided that the Plan has to pay forthe periodontal scalings and root planings of the upper left, lower left, and lower right quadrants. We also decided that the Plandoes not have to pay forthe endodontic therapy, miscellaneous dental service, extraction of an erupted tooth or exposed root, and two additional extractions of an erupted tooth requiring removal of bone and/or sectioning of tooth.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, endodontic therapy and miscellaneous dental service are not among those covered under this benefit. The contract says that extractions are limited to three procedures per calendar year. The record shows that you received extractions on May 15, 2019 and July 25, 2019 and your extractions benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe endodontic therapy, miscellaneous dental service, extraction of an erupted tooth or exposed root, and two additional extractions of an erupted tooth requiring removal of bone and/or sectioning of tooth.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.