Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We  decided the Plan does not have to pay more for a periodic oral evaluation - established patient (D0120), 
periodic oral evaluation - established patient (D0220), bitewings - four radiographic images (D0274), 
prophylaxis - adult (D1110) provided on October 11, 2022. We also decided that the Plan does not have to 
waive the coinsurance for the crown - porcelain/ceramic (D2740), and core buildup, including any pins when 
required (D2950), provided on October 18, 2022. 
 
You asked the Plan to waive the coinsurance for codes represented by D2740 and D2950. You say that you 
were unaware that the dentist was out-of-network. You also say that this is a burden to pay as you are on a 
fixed income. The Plan denied your request. The Plan says the coinsurance was appropriately applied to the 
crown  porcelain/ceramic, and core buildup, including pins when required. The Plan says that the dental 
services represented by D0120, D0220, D0274, and D1110 are covered, but for services obtained OON the 
plan only pays up to a certain amount. If you choose to see an OON dentist, you might be billed for any amount 
greater than what the plan pays, even for services listed as $0 copayment. 
 
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 50% 
coinsurance for crowns - porcelain/ceramic, and core buildup, including any pins when required. 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. 
 
 
DATE OF 
SERVICE 
 
 
CODE 
 
TOTAL 
CLAIMED 
 
TOTAL 
ALLOWED 
TOTAL 
PLAN 
PAID 
50% 
COST 
SHARE 
BILLED 
MINUS 
ALLOWED 
 
MEMBER 
LIABILITY 
10/11/2022 D1110 $120.00 $46.00 $46.00 $0 $74.00 $74.00 
10/11/2022 D0274 $75.00 $28.00 $28.00 $0 $47.00 $47.00 
10/11/2022 D0120 $63.00 $21.00 $21.00 $0 $42.00 $42.00 
10/11/2022 D0220 $37.00 $11.00 $11.00 $0 $26.00 $26.00 
10/18/2022 D2740 $1454.00 $536.00 $268.00 $268.00 $918.00 $1,186.00 
10/18/2022 D2950 $352.00 $112.00 $56.00 $56.00 $240.00 $296.00 
TOTAL       $1671.00 
 
You have been asked to pay a 50% coinsurance for codes represented by D2740 and D2950. The crown - 
porcelain/ceramic (D2740) falls within the crowns, inlays and onlays benefit category. The  core buildup, 
including any pins when required (D2950) falls within the other restorative services. 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 for the crown - porcelain/ceramic (D2740), and core buildup, including any pins when 
required (D2950) provided on October 18, 2022. The Plan also does not have to pay more for the periodic oral 
evaluation - established patient (D0120), periodic oral evaluation - established patient (D0220), bitewings - 
four radiographic images (D0274), prophylaxis - adult (D1110) provided on October 11, 2022.