Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to pay more for the dental services. We decided that the Plan does not have to pay in full for the anterior resin-based composite (D2330), posterior resin-based composite (D2392), periodic oral evaluation (D0120), prophylaxis (D1110), and amalgam (D2150) provided on July 26, 2021, and August 18, 2021 by an out-of-network (OON) provider.   You asked the Plan to pay for the anterior resin-based composite (D2330) and posterior resin-based composite (D2392), and to pay more for the periodic oral evaluation (D0120), prophylaxis (D1110), and amalgam (D2150). The Plan says that the OON accessed amount was applied correctly per your plan benefits. The Plan also says that you have exceeded limits set in the subscriber agreement, and the $500 benefit max was met when processing the claim.  We decided that the Plan has to pay more for the dental services.   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.  We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of these dental services have been met. The 2021 Evidence of Coverage states that you have a $1,000 annual maximum dental allowance. Once the $1,000 allowance is exhausted, you are responsible for the full charges of any additional dental services. The record shows that the Plan met up to only a $500 allowance, leaving $500 of the allowance still available to you. You reasonably believed a greater amount of these services, up to the $1,000 maximum benefit, would be covered. Therefore, we decided that the Plan has to pay more for the dental services.   We also decided that the Plan does not have to pay in full for the anterior resin-based composite (D2330), posterior resin-based composite (D2392), periodic oral evaluation (D0120), prophylaxis (D1110), and amalgam (D2150).  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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. You are also responsible for the difference between the billed amount and allowed amount for the services being rendered OON. Therefore, we decided that the Plan does not have to pay in full for the anterior resin-based composite (D2330), posterior resin-based composite (D2392), periodic oral evaluation (D0120), prophylaxis (D1110), and amalgam (D2150).  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.