Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extra-oral posterior dental radiographic image (D0251), 
mandibular partial denture (D5214), surgical extraction (D7210), problem focused limited oral evaluation 
(D0140), intraoral periapical x-rays (D0220 and D0230), and panoramic x-ray (D0330) provided on February 
2, 2022, and February 16, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the extra-oral posterior dental radiographic image, mandibular partial denture, 
surgical extraction, problem focused limited oral evaluation, intraoral periapical x-rays, and panoramic x-ray. 
The Plan denied your request. The Plan says the extra-oral posterior dental radiographic image is not a covered 
expense under your dental plan. Your benefits for the problem focused limited oral evaluation, intraoral 
periapical x-rays, and panoramic x-ray have been satisfied, and the frequency limitations have been exceeded. 
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 covered 
services. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the extra-oral posterior dental 
radiographic image is not among those covered under this benefit. The contract says that you are responsible 
for a 55 percent coinsurance for the surgical extraction, and a 75 percent coinsurance for the mandibular partial 
denture, plus the difference between the billed amount and the allowed amount because these services were 
received OON.  
 
This benefit includes periodic oral exams and emergency diagnostic exams, and share a frequency limitation of 
two procedure codes per calendar year. The record shows that you received a periodic oral evaluation on 
January 4, 2022, and a problem focused limited oral evaluation on January 20, 2022, and your exams benefit 
has been exhausted. The contract says intraoral x-rays are limited to one procedure code per calendar year. The 
record shows that you received a first intraoral periapical x-ray on January 20, 2022, and your intraoral x-rays 
benefit has been exhausted. The Plan contract also says full mouth or panoramic x-rays share a frequency 
limitation of one procedure code every five calendar years. The record shows that you received a complete 
series of intraoral x-rays on January 29, 2022, and your full mouth or panoramic x-rays benefit has been 
exhausted.  
 
Therefore, we decided that the Plan does not have to pay for the extra-oral posterior dental radiographic image 
(D0251), mandibular partial denture (D5214), surgical extraction (D7210), problem focused limited oral 
evaluation (D0140), intraoral periapical x-rays (D0220 and D0230), and panoramic x-ray (D0330) provided on 
February 2, 2022, and February 16, 2022 by an out-of-network (OON) provider.