Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the comprehensive oral evaluation (D0150). We decided that the Plan does not have to pay for the diagnostic casts (D0470) and occlusal adjustment (D9952).
You asked the Plan to pay for the comprehensive oral evaluation (D0150), diagnostic casts (D0470), and occlusal adjustment (D9952). You say that you would like these claims to be reviewed under the medical portion of your insurance, and not the very limited dental portion. The Plan says that diagnostic casts and occlusal adjustment are not covered benefits under your dental plan. The Plan also says that the OON liability was applied correctly for the comprehensive oral evaluation.
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150).
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for temporomandibular joint (TMJ) syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the comprehensive oral evaluation (D0150). Our reviewer says that the comprehensive oral evaluation (D0150) to determine the etiology of the condition meets the criteria for coverage. Our physician reviewer found the comprehensive oral evaluation (D0150) is medically reasonable and necessary to arrive at a diagnosis and therefore, meets the criteria for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the comprehensive oral evaluation (D0150) have been met. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation (D0150).
We also decided that the Plan does not have to pay for the diagnostic casts (D0470) and occlusal adjustment (D9952).
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for temporomandibular joint (TMJ) syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the diagnostic casts (D0470) and occlusal adjustment (D9952). Our reviewer says that the documentation provided does not meet the criteria for coverage for diagnostic casts (D0470) and occlusal adjustment (D9952). Our physician reviewer found diagnostic casts and occlusal adjustment are dental in nature and therefore, would not be eligible for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the diagnostic casts (D0470) and occlusal adjustment (D9952) have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic casts (D0470) and occlusal adjustment (D9952).
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 leter