Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay 50% of the cost for the two surgical extractions (D7210 x2), bone 
replacement graft for ridge preservation (D7953), deep sedation/general anesthesia (D9223), intravenous 
moderate (conscious) sedation/analgesia (D9243), and unspecified adjunctive procedure (D9999) provided on 
August 24, 2021. 
 
You asked the Plan to pay for the surgical extractions, bone replacement graft, deep sedation/general 
anesthesia, intravenous moderate (conscious) sedation/analgesia, and unspecified adjunctive procedure. You 
say that the dental work performed was medically necessary. You also say that without this treatment, your 
medical conditions would further decline. The Plan denied your request. The Plan says that bone replacement 
graft for ridge preservation, deep sedation/general anesthesia, and unspecified adjunctive procedure are non-
covered charges. The Plan also says that intravenous moderate (conscious) sedation/analgesia is only payable 
when the primary code has been submitted and paid on the same date of service. 
 
Medicare rules say that the health plan must provide you with a clear and accurate description of the Original 
Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including 
applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. 
 
 
  The record shows that the services you received were denied by the Plan as not being covered. The 2021 
Evidence of Coverage states that non-routine comprehensive dental services are limited to 1 every 6 to 24 
months. The contract also says that you are responsible for 50% of the cost for each supplemental dental 
service covered by the Plan. The EOC does not clearly state which dental codes are covered, nor does it 
provide specific limitations or exclusions for certain benefits. The documentation does not show that you have 
exhausted your benefits for any of the provided services. You reasonably believed you would only be 
responsible for 50% of the total because non-routine services are listed as a covered benefit. Based on this 
information we find that the Plan must reimburse you 50% of the amount you paid of $2,877. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the surgical extractions, bone replacement graft, deep sedation/general anesthesia, intravenous 
moderate (conscious) sedation/analgesia, and unspecified adjunctive procedure have been met. Therefore, we 
decided that the Plan has to pay 50% of the amount you paid of $2,877 for the two surgical extractions (D7210 
x2), bone replacement graft for ridge preservation (D7953), deep sedation/general anesthesia (D9223), 
intravenous moderate (conscious) sedation/analgesia (D9243), and unspecified adjunctive procedure (D9999) 
provided on August 24, 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.