Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayments for the root canal and root canal retreatment. We 
decided that the Plan does not have to fully waive the copayments for these services.  
 
You asked the Plan to reduce the copayments for the root canal and root canal retreatment. You say that you 
were not aware you would owe a copayment for these services. The Plan says that the schedule of benefits 
states that there is a $20 copayment for a root canal (D3310) and a $295 copayment for a root canal retreatment 
(D3346). The Plan says this claim was processed correctly.  
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.  
 
The rules also 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 does not say in clear and 
accurate terms how much you should expect to pay for a root canal or a root canal retreatment. 
 
We decided that the Plan has to reduce the copayments for the root canal and root canal retreatment.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $20 
copayment for a root canal (D3310) and a $295 copayment for a root canal retreatment (D3346). The Plan 
mentions an additional document in their argument, but this document was not submitted to us for review. The 
Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  
 
The Plan contract does not clearly say how much enrollees must pay for either of these services specifically, 
and the only information in the contract states that endodontic services require a copayment that is between $15 
and $295. Without additional information, we cannot verify the specific copayments required for each of these 
services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. 
With the information available, we cannot verify that each of these services requires more than a $15 
copayment. Therefore, we decided that the Plan has to reduce the copayment for the root canal (D3310) and the 
root canal retreatment (D3346) provided on April 22, 2021, to $15 each. 
 
We also decided that the Plan does not have to fully waive the copayments for these services. 
 
While the exact copayment amount is unclear from the contract and the information provided for review, it is 
clear from the contract that some copayment is required for covered endodontic services. Therefore, we 
decided that the Plan does not have to fully waive the copayments for the endodontic services provided on 
April 22, 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.