Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for a intraoral - periapical first radiographic image (D0220), each 
additional radiographic image (D0230), and the bitewings - four radiographic images (D0274). We 
decided that the Plan does not have to pay for the periodic oral evaluation (D0120), and the periodontal 
maintenance (D4910).  
 
You asked the Plan to pay for a periodic oral evaluation - established patient (D0120), periodontal maintenance 
(D4910), intraoral - periapical first radiographic image (D0220), each additional radiographic image (D0230), 
and the bitewings - four radiographic images (D0274). You say that the dentist did not inform you how much 
the cost of the services would be. You also say that you cannot afford the bill.  The Plan says that the periodic 
oral evaluation (D0120), and periodontal maintenance (D4910) has already been exhausted. 
 
We decided that the Plan has to pay for a to pay for a intraoral - periapical first radiographic image 
(D0220), each additional radiographic image (D0230), and the bitewings - four radiographic images 
(D0274).  
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request for the intraoral - periapical first radiographic image (D0220), each additional radiographic image 
(D0230), and the bitewings - four radiographic images (D0274). There is no evidence showing that you had 
these services in the last two years. Therefore, we decided that the Plan has to pre-approve the intraoral - 
periapical first radiographic image (D0220), each additional radiographic image (D0230), and the bitewings - 
four radiographic images (D0274). 
 
We also decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and the 
periodontal maintenance (D4910). 
 
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 periodic oral evaluation (D0120), and periodontal maintenance (D4910) was exhausted on 
date of service June 20, 2022. Therefore, we decided that the Plan does not have to pay for the periodic oral 
evaluation (D0120), and periodontal maintenance (D4910). 
 
 
 
 
 
 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.