Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay more for the simple extraction (D7140) and resin-based composites 
(D2330 and D2331). We decided that the Plan does not have to pay for the full mouth debridement (D4355).  
 
You asked the Plan to pay for the full mouth debridement (D4355) and to pay more for the simple extraction 
(D7140) and resin-based composites (D2330 and D2331) provided from July 29, 2021, to September 14, 2021 
by an out-of-network (OON) provider. You say that these services should have been covered in full after the 
copayment was paid. The Plan says that the full mouth debridement is not a covered expense under your dental 
plan. The Plan also says that these services were performed by a non-participating provider, and you are 
responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for 
the services. 
 
We decided that the Plan has to pay the difference between the billed amount and allowed amount for 
the simple extraction (D7140) and resin-based composites (D2330 and D2331).  
 
The Plan follows Medicare rules. 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 you received a simple extraction (D7140) and resin-based composites (D2330 and 
D2331) from an OON provider. The 2022 Evidence of Coverage lists these services as covered benefits under 
your dental Plan, and shows you are responsible for 0% when the services are rendered by an OON provider. 
The contract does not clearly state that you can expect to be charged the difference between the provider's 
billed amount and the Plan's allowed amount if the services are received OON. You reasonably believed these 
services would be covered because the contract does not state otherwise. Therefore, we decided that the Plan 
has to pay the difference between the billed amount and allowed amount for the simple extraction (D7140) and 
resin-based composites (D2330 and D2331).  
 
We also decided that the Plan does not have to pay for the full mouth debridement (D4355). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full 
mouth debridement (D4355). 
 
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.