Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the limited oral evaluation (D0140) and intraoral x-ray (D0220) provided on March 30, 2021.
You asked the Plan to pay for the evaluation and x-ray. You say that you enrolled in the Plan's additional optional rider effective April 1, 2021, and you assumed the services would be covered up to the limit of the optional rider. The Plan denied your request. The Plan says that you had dental services provided in April of 2021, which were processed prior to the services received on the date in question. The Plan had already paid the maximum amount of $500 before these services were processed for payment, and therefore payment is denied.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. While covered under the Plan's mandatory dental benefit, there is an annual limit of $500 for covered dental care. While covered under the Plan's additional optional dental benefit, there is an annual limit of $1,500 for covered dental services. We looked at the file and Medicare rules. The record indicates that you received the services in question on March 30, 2021. You say that you then enrolled in the Plan's additional dental rider, which became effective on April 1, 2021. The Plan's timeline corroborates this information. You then received additional services on April 8, 2021, and April 20, 2021. The Plan paid a total of $644 for the services provided on these dates, as the April claims were submitted for processing first. When the date in question was submitted for payment, the Plan denied the claim stating that you had already met and exceeded your $500 annual allowance for dental care in 2021.
However, at the time of the April dates of service, you were enrolled in the Plan's additional optional dental rider, which has an annual limit of $1,500 per year. These services should have been counted toward that maximum only and not the $500 maximum for services provided without this rider. In addition, the services provided on March 30, 2021, occurred before the services provided in April, and were denied because the Plan counted the services provided while enrolled in the optional rider in the Plan's mandatory rider maximum. You cannot be held responsible for the order in which a contracted provider submits claims to the Plan. Had the March services been processed first, there would have been no issue as the annual limit increased to $1,500 once you were enrolled in the additional optional benefits in April.
These services are listed as covered benefits under the mandatory dental rider and did not exceed the Plan's $500 annual maximum at the time of service. Based on this information, we decided that the Plan's rules for coverage of the evaluation and x-ray have been met. Therefore, we decided that the Plan has to pay for the limited oral evaluation (D0140) and intraoral x-ray (D0220) provided on March 30, 2021.
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.