Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the simple extractions (D7140) of tooth #s 1 and 23 and surgical 
extraction (D7210) of tooth #21. We decided that the Plan does not have to pay for the surgical extractions 
(D7210) of tooth #'s 5, 6, 7, and 8.  
 
You asked the Plan to pay for the simple extractions (D7140) of tooth #s 1 and 23 and surgical extractions 
(D7210) of tooth #'s 5, 6, 7, 8, and 21 provided from September 9, 2021, to November 8, 2021. You say that 
you were told that you had $2,500 that you could use for dental work for 1 calendar year, but were not told that 
you could only have 8 teeth pulled in that year. The Plan says that these services have limits on how often they 
can be paid in 12 months. The Plan also says that these limits have already been reached. 
 
We decided that the Plan has to pay for the simple extractions (D7140) of tooth #s 1 and 23 and surgical 
extraction (D7210) of tooth #21.  
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable medical records to support that 
a surgical extraction (D7210) of tooth #21 is not supported. The Plan also did not provide proof as to any other 
simple extractions (D7140) that were covered by the Plan, exhausting the enrollees benefit of 8 simple 
extractions (D7140) per calendar year. Without this information we cannot determine that the Plan's coverage 
rules support the denial of payment in this case. Consequently, the Plan has not substantiated their denial of 
payment in this case. Therefore, we decided that the Plan has to pay for the simple extractions (D7140) of tooth 
#s 1 and 23 and surgical extraction (D7210) of tooth #21.  
 
We also decided that the Plan does not have to pay for the surgical extractions (D7210) of tooth #'s 5, 6, 
7, and 8. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are allowed up to 3 surgical 
extractions (D7210-D7241) every calendar year. The record shows you received surgical extractions (D7210) 
of tooth #'s 20, 21, and 22 which are all covered by the Plan, and your surgical extractions (D7210-D7241) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the surgical 
extractions (D7210) of tooth #'s 5, 6, 7, and 8. 
 
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.