Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the fixed bridgework (D6056, D6068, D6245) provided on August 3, 2021. We decided that the Plan does not have to pay for the partial denture (D5820).
You asked the Plan to pay for the denture and bridgework. You say that these services are necessary, and you do not understand why they are not being covered as your contract states that bridgework is a covered benefit. The Plan says that these services are not covered by your dental benefit, and therefore you are responsible for these costs.
We decided that the Plan has to pay for the bridgework (D6056, D6068, D6245) provided on August 3, 2021.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's rules apply in this case. The Plan covers restorative dental services, including fillings, onlays, crowns and bridges.
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. Medicare rules also say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.
We looked at the file, the Plan's rules, and Medicare rules. On the date in question, you received a dental bridge from an in-network provider. The Plan denied payment for these services, stating they are not covered. The Plan's contract states that bridgework is a covered service under the mandatory dental benefit. No documentation was provided to support that the specific codes at issue are excluded from coverage, nor was there documentation of any other exclusions or medical reasons for why these services should not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request.
In addition, you were referred for the bridgework services by a contract provider. The file does not show that the Plan provided notice that the bridgework services would not be covered. Under Medicare rules, this means these services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the dental bridgework (D6056, D6068, D6245) provided on August 3, 2021.
We also decided that the Plan does not have to pay for the partial denture (D5820) provided on August 3, 2021.
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 the Plan's contract states that adjustments and repairs of prosthetics, such as denture repairs, are a covered service under the Plan's dental benefit, dentures themselves are not listed as covered. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial denture (D5820) provided on August 3, 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.