Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for one intraoral periapical x-ray (D0707). We decided that the Plan does not have to pay for the one additional intraoral periapical x-ray, protective restoration, three core buildups, and one additional crown.
You asked the Plan to pay for the two intraoral periapical x-rays (D0707 x2), protective restoration (D2940), three core buildups, including any pins when required (D2950 x3), and one additional crown (D2740). You say that you understand that the treating provider is OON, but your policy has some OON coverage. The Plan says that the intraoral periapical x-rays, protective restoration, and core buildups are not covered benefits. The Plan also says that your crown benefit has been satisfied and the frequency limitation has been exceeded.
We decided that the Plan has to pay for one intraoral periapical x-ray (D0707).
The Plan follows Medicare rules. Medicare rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. The record shows that you received two intraoral periapical x-rays (D0707) which were denied by the Plan as not covered services. Your 2021 Evidence of Coverage (EOC) states that intraoral x-rays are limited to one procedure code per calendar year. The EOC does not clearly list specific codes that are, or are not, covered by the Plan. The Plan also provided no evidence that your intraoral x-rays benefit has been exhausted. Consequently, you reasonably believed one intraoral periapical x-ray would be covered. Therefore, we decided that the Plan has to pay for one intraoral periapical x-ray (D0707).
We also decided that the Plan does not have to pay for the one additional intraoral periapical x-ray, protective restoration, three core buildups, and one additional crown.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the protective restoration (D2940) and core buildup, including any pins when required (D2950) are not among those covered under this benefit. The contract says that crowns are limited to two procedure codes per calendar year, and you are responsible for a 75% coinsurance for crowns that are received out-of-network. The record shows that you received two crowns on February 8, 2021 which were covered at the out-of-network benefit rate by the Plan and your crowns benefit has been exhausted. The contract also says that intraoral x-rays are limited to one procedure code per calendar year. Therefore, we decided that the Plan does not have to pay for the one additional intraoral periapical x-ray, protective restoration, three core buildups, and one additional crown.
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.