Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the crown and core buildup services 
received on October 5, 2021 and the resin based composite services received on November 16, 2021. 
 
You asked the Plan to waive the coinsurance for the crown and core buildup services and the resin based 
composite services. You say that you disagree with the plan's coinsurance amount. The Plan denied your 
request. The Plan says the claims have been processed correctly per your plan benefits. 
 
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, periodontic, and oral surgery dental services. Your contract with the Plan clearly 
says that you must pay 20% coinsurance for the covered charges for restorative dental services (fillings). 
 
 You have been asked to pay 50% coinsurance for the crown and core buildup services and 20% coinsurance for 
the resin based composite services. The crown and core buildup services and the resin based composite services 
falls within the dental services benefit category. 
The following is the breakdown of the coinsurance due for the services received: 
You received services coded D2331 (resin-based composite - two surfaces, anterior) on tooth #7 and #10 in 
which the allowed amount is $90.00 per tooth. You received services coded D2332 (resin-based composite - 
three surfaces, anterior) on tooth #9 in which the allowed amount is $110.00 per tooth. After Plan paid benefits, 
you are responsible for a total coinsurance of 20% per tooth $90.00 (20%) + $110.00 (20%) = $40.00. 
 
You received services for code D2740 (crown - porcelain/ceramic) on tooth #12 in which the allowed amount 
is $700.00 per tooth. Under your supplement, a benefit amount of $210.00 was applied up to the quarterly max 
for claim number 0034198516 and reprocessed per your optional supplemental benefit under claim number 
0034601864 in which a benefit amount of $350.00 was applied, leaving you a coinsurance in the amount of 
$140.00 ($210.00 + $350.00 = $560.00 + $140.00 = $700.00). 
 
You received services for code D2950 (core buildup, including any pins when required) on tooth #12 in which 
the allowed amount is $100.00 per tooth. After Plan paid benefits, you are responsible for a total coinsurance of 
50% per tooth $100.00 (50%) = $50.00. You received services for D7210 (extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated) on 
tooth #6, #13, #15, #17 and #32 in which the allowed amount is $135.00 per tooth. After Plan paid benefits, the 
member is responsible for a total coinsurance of 50% per tooth $135 x 4 (50%) =$270.00. 
 
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 and core buildup services received on October 5, 
2021 and the resin based composite services received on November 16, 2021.