Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayments for the two root canals (D3331 x2) and surgical 
extraction (D7210). We decided that the Plan does not have to pay for the two core buildups, including any 
pins when required (D2950 x2), guided tissue regeneration (D4266), pontic (D6245), two retainer crowns 
(D6740 x2), and bone replacement graft for ridge preservation (D7953).  
 
You asked the Plan to pay for the two core buildups, including any pins when required (D2950 x2), two root 
canals (D3331 x2) guided tissue regeneration (D4266), pontic (D6245), two retainer crowns (D6740 x2), 
surgical extraction (D7210), and bone replacement graft for ridge preservation (D7953) provided on January 
21, 2022. The Plan says that the procedure code for the surgical extraction is not eligible. The Plan says that 
guided tissue regeneration, retainer crown, and bone replacement graft for ridge preservation are not covered 
under your plan. The Plan also says that the charges for the core buildups and pontic exceed the allowable rates 
for these services. 
 
We decided that the Plan has to reduce the copayments for the two root canals (D3331 x2) and surgical 
extraction (D7210).  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the two root canals (D3331 x2) and surgical extraction (D7210) have been met. The contract does 
not clearly state the exact amounts you must pay for root canals and extractions, but rather states a range you 
may be responsible for. The Plan will need to pay an additional $25 for the extraction, $140 for the root canal 
on tooth #4, and $80 for the root canal on tooth #8. Therefore, we decided that the Plan has to reduce the 
copayments for the two root canals (D3331 x2) and surgical extraction (D7210).  
 
We also decided that the Plan does not have to pay for the two core buildups, including any pins when 
required (D2950 x2), guided tissue regeneration (D4266), pontic (D6245), two retainer crowns (D6740 
x2), and bone replacement graft for ridge preservation (D7953). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. The record shows that you signed a consent form acknowledging that 
these services would not be covered. Therefore, we decided that the Plan does not have to pay for the two core 
buildups, including any pins when required (D2950 x2), guided tissue regeneration (D4266), pontic (D6245), 
two retainer crowns (D6740 x2), and bone replacement graft for ridge preservation (D7953). 
 
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.