Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120), dental cleaning (D1110), 
full mouth x-rays (D0210), re-cement or re-bond of crown (D2920) and topical fluoride application with 
varnish (D1206) provided on September 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that you feel this claim must have been processed 
incorrectly, because you expected a larger payment from the Plan. The Plan denied your request. The Plan says 
re-cementing/re-bonding of a crown and topical fluoride application with varnish are not covered services 
under your dental benefit. The cleaning, exam and full mouth x-rays are covered services, and the Plan has paid 
the full allowed amount for this care; however, the provider in this case is not part of the Plans dental network 
and is allowed to charge you the difference between the full billed amount and the Plans price. 
 
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. The Plan does not cover 
services that are not listed as covered in the dental benefits chart section of the contract. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, fluoride application with varnish and 
recementing/re-bonding of a crown are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for the re-cement or re-bond of crown (D2920) and topical fluoride application 
with varnish (D1206) provided on September 23, 2021. 
 
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 0% 
coinsurance for periodic oral exams, full mouth x-rays and prophylaxis (cleanings) regardless of whether they 
are performed by an in-network or out-of-network provider. However, network dentists have agreed to provide 
services at a negotiated rate. If you see a network dentist, you cannot be billed more than this rate for covered 
services. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or 
exclusions. You may be billed by an out-of-network provider for any amount greater than the payment made by 
the Plan to the provider. 
 
The provider in this case is out-of-network. Documentation shows that the provider billed a total of $341 for 
the cleaning, exam and x-rays provided on September 23, 2021. The Plans total allowed amount for these 
services is $156. This is the amount that an in-network provider would accept as full payment for these 
services, but out-of-network providers do not have this agreement with the Plan and are allowed to bill you the 
remaining charges. You are responsible for only this difference in cost, because you are responsible for 0% 
coinsurance on the Plans allowed amount for these services. ($341 - $156 = $185). This means that you have 
been asked to pay the correct amount and have been reimbursed 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 pay an additional amount for for the periodic oral exam 
(D0120), dental cleaning (D1110) or full mouth x-rays (D0210) provided on September 23, 2021.