Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost share for a crown (code D2751) provided on February 24, 
2022. We also decided that the Plan does not have to waive the cost share for endodontic therapy (code D3320) 
and core build up (code D2960) provided on February 8, 2022.  
 
You asked the Plan to waive the cost share for endodontic therapy and core build up. You say that you received 
a denial for services that you were told was covered. The Plan says that you have been charged the correct cost 
sharing amount. 
 
We decided that the Plan has to reduce the cost share for a crown provided on February 24, 2022.  
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records to show why replacing code D2740 
with code D2751 for a crown was appropriate. Without the medical records we are unable to determine if the 
cost sharing amount is correct. Therefore, we decided that the Plan has to reduce the cost share for a crown 
provided on February 24, 2022. The allowed amount for code D2740 is $840, you are responsible for 50% 
coinsurance of the allowed amount for a crown ($840 allowed amount x 50% coinsurance = $420).  
 
We also decided that the Plan does not have to waive the cost share for endodontic therapy and core 
build up provided on February 8, 2022. 
 
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 50% 
coinsurance for endodontic therapy and core build up.  
 
You have been asked to pay $94, which is 50% coinsurance of the allowed amount for core build up ($188 
allowed amount x 50% coinsurance = $94). You have also been asked to pay $332.50, which is 50% 
coinsurance of the allowed amount for endodontic therapy ($665 allowed amount x 50% coinsurance = 
$332.50). You have been asked to pay a total of $426.50 for services on February 8, 2022 ($94 coinsurance + 
$332.50 coinsurance = $426.50). Endodontic therapy and core build up fall within the Medicare 
Dental Option 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 cost share for endodontic 
therapy (code D3320) and core build up (code D2960) provided on February 8, 2022. 
 
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.