Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for bitewings - four radiographic images (D0274), intraoral 
- periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image 
(D0230), comprehensive oral evaluation (D0150), prophylaxis - adult (D1110), resin-based composite - three 
surfaces, anterior (D2332), resin-based composite - two surfaces, anterior (D2331 x2), resin-based composite - 
one surface, posterior (D2391), and resin-based composite - one surface, posterior (D9420) provided on 
September 14, 2022. You received an additional resin-based composite  two surfaces, anterior (D2331) on the 
appealed claim, and a resin-based composite  one surface, posterior (D2391) at the same visit. 
 
You asked the Plan to pay more for the dental services. You say that are unclear why the claims denied for 
service and believe that they may have been submitted/processed in duplicate. The Plan denied your request. 
The Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider. The Plan confirmed the extractions, erupted tooth or 
exposed root (D7140) were not needed to prepare the jaw for radiation treatments. The Plan also confirmed that 
this treatment was not performed in an inpatient facility setting but a standard providers office/outpatient 
setting. The Plan says the bitewings - four radiographic images (D0274), comprehensive oral evaluation 
(D0150), and prophylaxis - adult (D1110) were rendered by an out-of-network provider and the Plan paid the 
allowed amount, therefore any remaining balance for this service is your responsibility.   
 
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, certain limitations apply. The record 
shows your benefit for the intraoral - periapical first radiographic image (D0220), and intraoral  periapical 
each additional radiographic image (D0230) was exhausted on date of service February 8, 2022. The record 
shows the resin-based composite - three surfaces, anterior (D2332), resin-based composite - two surfaces, 
anterior (D2331), and resin-based composite - one surface, posterior (D2391) was exhausted on the appealed 
claim. 
 
You have 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. 
 
You have 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. 
Therefore, we decided that the Plan does not have to pay more for bitewings - four radiographic images 
(D0274), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional 
radiographic image (D0230), comprehensive oral evaluation (D0150), prophylaxis - adult (D1110), resin-based 
composite - three surfaces, anterior (D2332), resin-based composite - two surfaces, anterior (D2331 x2), resin-
based composite - one surface, posterior (D2391), hospital or ambulatory surgical center call (D9420), and 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on September 
14, 2022.