Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography capture (D0364), a canal 
preparation (D3950), and an intraoral periapical X-ray (D0220) received on September 28, 2020. We also 
decided that the Plan does not have to waive the coinsurance for a limited oral evaluation (D0140) and 
endodontic therapy (D3310) received on September 28, 2020. 
 
You asked the Plan to pay for a cone beam computed tomography capture, a canal preparation, and an intraoral 
periapical X-ray, and to waive the coinsurance for a limited oral evaluation and endodontic therapy. You say 
that these services were necessary. The Plan denied your request. The Plan says rules for payment have not 
been met or that the correct cost-sharing has already been applied. 
 
We decided that the Plan does not have to pay for a cone beam computed tomography capture and a 
canal preparation. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam computed tomography capture (D0364) and a canal preparation (D3950) received on September 28, 
2020. 
 
We also decided that the Plan does not have to pay for an intraoral periapical X-ray. 
 
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 an intraoral 
periapical X-ray once per calendar year.  
 
In this case, the record shows that you previously received an intraoral periapical X-ray on September 17, 
2020. Based on this information, the Plan's rules for coverage of an intraoral periapical X-ray received on 
September 28, 2020, have not been met because the annual benefit was exhausted for 2020. Therefore, we 
decided that the Plan does not have to pay for an intraoral periapical X-ray (D0220) received on September 28, 
2020. 
 
Finally, we decided that the Plan does not have to waive the coinsurance for a limited oral evaluation and 
endodontic therapy. 
 
The rules 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 must pay 50% 
coinsurance for an oral evaluation and 75% coinsurance for endodontic therapy when obtained from an out of 
network provider.  
 
You have been asked to pay $17.00, or 50% of the Medicare-allowed amount of $34.00, for an oral evaluation 
obtained from an out of network provider, and $315.00, or 75% of the Medicare-allowed amount of $420.00, 
for endodontic therapy obtained from an out of network provider. 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. Note that the out of network provider may choose to bill you for 
the difference between the Medicare-allowed amount and the provider?s total charge. Therefore, we decided 
that the Plan does not have to waive the coinsurance for a limited oral evaluation (D0140) and endodontic 
therapy (D3310) received on September 28, 2020.