Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for crown - porcelain/ceramic (D2740 x2) 
provided on January 13, 2022. We also decided that the Plan to pay for core buildup, including any pins when 
required (D2950), pontic - porcelain/ceramic (D6245), provided on January 13, 2022. We also decided the Plan 
does not have to pay for the  intraoral - periapical first radiographic image (D0220), and each additional 
radiographic image (D0230) provided on January 13, 2022, and February 18, 2022. 
 
You asked the Plan to waive the coinsurance/adjust the cost sharing for the crown - porcelain/ceramic (D2740 
x2). You also asked the Plan to pay for the core buildup, including any pins when required (D2950), pontic - 
porcelain/ceramic (D6245). You also ask the plan pay for intraoral - periapical first radiographic image 
(D0220), and each additional radiographic image (D0230). You say that were not aware that the provider was 
out-of-network. The Plan denied your request. The Plan says the coinsurance was appropriately applied to the 
crown  porcelain/ceramic provided. The Plan says that the dental services represented by codes D2950 and 
D6245 are not covered under the enrollees benefits. The Plan also says that the  intraoral - periapical first 
radiographic image (D0220), and each additional radiographic image (D0230) has already been exhausted. 
 
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 a 75% 
coinsurance for crowns provided out-of-network.  
 
Medicare does not generally 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. 
 
You have been asked to pay a 75% coinsurance for the crown - porcelain/ceramic (D2740 x2) provided from 
an out-of-network provider. This service falls within the crowns provided out-of-network 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/adjust the cost sharing for the crown - porcelain/ceramic 
(D2740 x2) provided on January 13, 2022.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral - periapical first radiographic image (D0220), and each additional 
radiographic image (D0230) was exhausted on date of service January 13, 2022. Therefore, we decided that the 
Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), and each additional 
radiographic image(D0230) provided on January 13, 2022, and February 18, 2022. 
 
The dental services represented by codes D2950 and D6245 are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for a core buildup, including any pins when required 
(D2950),and pontic - porcelain/ceramic (D6245) provided on January 13, 2022.