Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210), implant placement (D6010),
bone graft (D6104) and fixed partial denture sectioning (D9120) provided on January 8, 2021.
You asked the Plan to pay for the dental services. You say that you do not understand why the extraction was
approved for payment, but the Plan has not paid for this service. The Plan denied your request. The Plan says
bone grafts and denture sectioning services are not covered by your dental benefit. The extraction and the
implant are covered; however, you are responsible for 50% of the Plan's allowed amount for these services
after you meet your $100 deductible. In addition, the provider you used was out-of-network, so you are
responsible for the difference between the provider's charges and the Plan's allowed amount for these services.
The payments have been applied correctly.
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 rules also say 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 are responsible for 50% coinsurance of the
Plan's allowed cost for major dental services (endodontics, periodontics, prosthodontics and oral surgery) after
you meet your $100 deductible. You can get care from an out-of-network dental provider, but you may pay
more.
Though the Plan offers a dental benefit in excess of Medicare coverage, bone grafts and denture sectioning
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the bone graft (D6104) and the fixed partial denture sectioning (D9120) provided on January 8, 2021.
You have been asked to pay $335 for the surgical extraction. The Plan's allowed cost for this service is $92.50.
Because you had not yet met your deductible, which is required before the Plan will pay any amount for basic
and major dental services, the full $92.50 was applied to your required $100 deductible. In addition, because
you used an out-of-network provider, you are responsible for the difference between the amount the provider
billed for the service and the Plan's allowed amount. Because the Plan's allowed amount for this service is less
than your required deductible and the deductible has not yet been met, you are responsible for the full $335
billed by the provider. This means that you have been asked to pay the correct amount based on your contract
with the Plan.
You have also been asked to pay $1,769.94 for the surgical implant placement. The Plan's allowed amount for
this service is $947.63. Before the Plan will pay their portion, you must first meet your deductible. Because the
$92.50 charge from the extraction was applied to your deductible, you must pay $7.50 to meet the required
$100 deductible. Once your deductible is met, you are responsible for half of what remains of the Plan's
allowed charge ($947.63 - $7.50 = $940.13). ($940.13 x 50% coinsurance = $470.06). This means that the Plan
will pay $470.06, and you will also pay $470.06, plus your $7.50 deductible. Because the provider who
rendered services is out-of-network, you are also responsible for the difference between what the provider
charged ($2,240) and the Plan's allowed amount for the services ($2,240 - $947.63 = $1,292.37). ($7.50
deductible + $470.06 coinsurance + $1,292.37 out-of-network cost difference = $1,769.94). 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 pay an additional amount for the surgical extraction (D7210) and implant
placement (D6010) provided on January 8, 2021.