Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and the coinsurance applied to the surgical 
removal of an erupted tooth (D7210) for teeth numbers 3 and 15, and deep sedation/general anesthesia (D9222, 
D9223) provided on October 3, 2022. We also decided the Plan has to pay for the therapeutic parenteral drug 
(D9610) provided on October 3, 2022. 
 
You asked the Plan to waive the deductible and the coinsurance applied to the surgical removal of an erupted 
tooth (D7210) for teeth numbers 3 and 15, and deep sedation/general anesthesia (D9222, D9223). You also 
asked the Plan to pay for the therapeutic parenteral drug (D9610). You say that you were told that the provider 
accepted your insurance, and that your dental work should be 80 to 100% covered. The Plan denied your 
request. The Plan says this cost sharing for the surgical removal of an erupted tooth (D7210) for teeth numbers 
3 and 15, and deep sedation/general anesthesia (D9222, D9223) was charged correctly. The Plan also says that 
the therapeutic parenteral drug (D9610) is not a covered benefit. 
 
Medicare generally does not 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. Medicare rules also say that a 
Plan must disclose to its enrollees in clear and accurate terms, all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
deductible for comprehensive dental services. Your contract with the Plan also says that you must pay a 50% 
coinsurance for non-Medicare covered basic and major dental services after the deductible has been met.  
 
You have been asked to pay a $100 deductible toward the cost of the dental extraction of tooth #3. This service 
falls within the comprehensive dental services benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. You have also been asked to pay a 50% coinsurance 
on the remaining balance due for the dental extraction of tooth #3 (50% x $100 = $50), a 50% coinsurance on 
the total allowed amount due for the dental extraction of tooth #15 (50% x $200 = $100), a 50% coinsurance on 
the total allowed amount due for the first 15 minutes of dental anesthesia ( 50% x $146 = $73), a 50% 
coinsurance for a subsequent 15 minute increment of dental anesthesia (50% x $146 = $73), and a 50% 
coinsurance for another subsequent 15 minute increment of dental anesthesia (50% x $36 = $18). These 
services fall within the non-Medicare covered basic and major dental services benefit category. This means that 
you have been asked to pay the correct amounts 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 deductible or coinsurances applied to the surgical removal of an erupted tooth 
(D7210) for teeth numbers 3 and 15, and deep sedation/general anesthesia (D9222, D9223) provided on 
October 3, 2022. Though the Plan offers a dental benefit in excess of Medicare coverage, therapeutic parenteral 
drugs are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the therapeutic parenteral drug (D9610) provided on October 3, 2022.