Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone replacement graft (D7953), deep sedation/anesthesia (D9222, D9223), extractions (D7210) and an unspecified preventative procedure (D1999) provided on November 5, 2020.
You asked the Plan to pay for the dental services. You say that you believed you had $2,000 of dental coverage and feel that you have been misled because these services were denied. You feel they should be covered in full because they were medically necessary. The Plan denied your request. The Plan says bone replacement grafts and unspecified preventative procedures are not covered by Medicare or by the Plan's supplemental dental benefit. The anesthesia and extractions are covered, and payment has processed correctly per your out-of-network cost-sharing and the provider's bill.
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, bone graft replacements and unspecified preventative procedures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone replacement graft (D7953) and an unspecified preventative procedure (D1999) provided on November 5, 2020.
The rules also say that 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 50% coinsurance for anesthesia and 55% coinsurance for extractions received from an out-of-network dental provider. Benefits received from out-of-network providers are subject to any in-network benefit maximums, limitations and/or exclusions. You may be billed by the out-of-network provider for any amount greater than the payment made to the Plan by the provider.
You received two extractions from an out-of-network provider. The provider charged $294 per extraction. The Plan's maximum allowed amount for this service is $127. This is a rate that in-network providers have agreed to charge for this service, but out-of-network providers have not agreed to this charge amount. You are responsible for 55% coinsurance of the allowed amount for extractions received out-of-network, as well as the amount greater than the payment made by the Plan to the provider. This means you must pay a coinsurance amount of $69.85 ($127 x 55% coinsurance = $69.85), and you may be billed the difference between the Plan's allowed amount for this service and the amount the provider billed ($294 - $127 = $167). This means you may be charged up to $236.85 ($167 + $69.85 = $236.85) for each extraction. This means that you have been asked to pay the correct amount based on your contract with the Plan. The Plan reprocessed and approved the claim for the anesthesia. The provider billed $296 for the first 15 minutes (D9222) and $236 for the following 15 minutes of anesthesia (D9223). These charges match the Plan's maximum allowed amount for anesthesia services. Anesthesia requires 50% coinsurance. The Plan paid $148 for the first 15 minutes ($296 x 50% = $148) and $118 for the following 15 minutes ($236 x 50% = $118). This means 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 pay more for the deep sedation/anesthesia (D9222, D9223) and extractions (D7210) provided on November 5, 2020.