Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the periodic oral evaluation (D0120) and 
the cleaning (D1110) and to pay for the pre-diagnostic test (D0431) and the application of fluoride (D1208) 
provided by an out-of-network provider on July 18, 2022.  
You asked the Plan to waive the coinsurance for the periodic oral evaluation and the cleaning and to pay for the 
pre-diagnostic test. You say that you did not know the dentist was an out-of-network provider. The Plan denied 
your request. The Plan says this cost sharing for the periodic oral evaluation and the cleaning charged correctly. 
Also, the denial of payment for the pre-diagnostic test and the application of fluoride is correct, because they 
are not covered by the Plan. 
 
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 30% 
coinsurance for out-of-network non-Medicare covered preventive dental services. The pre-diagnostic test and 
the application of fluoride are not covered by the Plan's dental benefits. The contract also says that enrollees 
may be billed by the out-of-network provider for any charged amount greater than the payment made by the 
Plan. The total amount allowed for the periodic oral evaluation was $71 with a coinsurance of $21.30 ($71 total 
x 30% coinsurance). The difference amount between what the provider billed was $3 ($74 billed - $71 total 
amount allowed). The total cost share amount for the periodic oral evaluation was $24.30 ($21.30 coinsurance 
+ $3 difference). The total amount allowed for the cleaning was $122 with a coinsurance amount of $36.60 
($122 total amount x 30% coinsurance). The difference amount between what the provider billed was $12 
($134 billed - $122 total amount allowed). The total cost share for the cleaning was $48.60 ($36.60 coinsurance 
+ $12 difference). The pre-diagnostic test was denied with a $10 cost share and the application of fluoride was 
denied with a $24 cost share. The total cost share amount was $106.90 ($24.30 cost share + $48.60 cost share + 
$10 cost share + $24 cost share). 
 
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. 
 
You have been asked to pay a $106.90 cost share for the dental services. This items/services falls within the 
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 the difference between the out-of-network providers 
charges and the Plans payment. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The pre-diagnostic test and the application of fluoride are not covered under the Plans 
dental benefit.  Therefore, we decided that the Plan does not have to waive the coinsurance for the periodic oral 
evaluation (D0120) and the cleaning (D1110) and to pay for the pre-diagnostic test (D0431) and the application 
of fluoride (D1208) provided by an out-of-network provider on July 18, 2022.