Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for a CT scan of the maxillofacial area, an oral surgery consultation, and an incision to treat fracture. We decided that the Plan does not have to waive the coinsurance for sedation/anesthesia services (D9222, D9223) provided on April 30, 2021.

You asked the Plan to pay for a CT scan of the maxillofacial area, an oral surgery consultation, and an incision to treat fracture and to waive the coinsurance for sedation/anesthesia services You say that the services at issue fall under medical coverage according to your plan. The Plan says that the services at issue are not a covered benefit or that the correct cost-sharing has already been applied.

We decided that the Plan has to pay for a CT scan of the maxillofacial area.

The rules state that PPO plans must provide reimbursement for all plan-covered medically necessary services received from non-contracted providers without prior authorization requirements. The rules also say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

In this case, the Plan denied payment for a CT scan of the maxillofacial area because prior authorization requirements had not been met. This is not a valid rationale for denial. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding the medical necessity of a CT scan of the maxillofacial area. Therefore, we decided that the Plan has to pay for a CT scan of the maxillofacial area (70486) provided on April 26, 2021.

We decided that the Plan has to pay for an oral surgery consultation and an incision to treat fracture.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

In this case, it does not appear that the surgery described by the code would be considered treatment of the teeth or supporting structures and would be eligible for Medicare coverage. As such, whether the service is covered under the dental benefit is not relevant. Furthermore, the Plan did not make any attempts to obtain medical records meaning that a review for medical necessity cannot be completed. Due to these issues, we find that the denial of payment for an oral surgery consultation and an incision to treat fracture is not supported. Therefore, we decided that the Plan has to pay for an oral surgery consultation (D9310) and an incision to treat fracture (D7750) provided on April 26 to April 30, 2021.

We also decided that the Plan does not have to waive the coinsurance for sedation/anesthesia services.

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 40% coinsurance after the deductible is met for each outpatient surgery and/or services at an out-of-network ambulatory surgical center or out-of-network outpatient hospital facility. 

You have been asked to pay $66, or 40% of the Medicare-allowed charge of $165, for every 15 minutes of sedation/anesthesia services. Sedation/anesthesia services fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. 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 waive the coinsurance for sedation/anesthesia services (D9222, D9223) provided on April 30, 2021.

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.