Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for a limited oral evaluation (D0140) provided on April 9, 2021, a periodic 
oral evaluation (D0120) provided on July 6, 2021, and a periapical x-ray (D0220) provided on April 8, 2022. 
We also decided that the Plan does not have to reduce the cost share for the fillings and crowns provided from 
July 31, 2020, to February 8, 2022, and does not have to pay for periapical x-rays provided on July 31, 2020, 
August 4, 2020, and June 1, 2022, and a filling and crowns provided from February 22, 2022, to June 1, 2022. 
 
You asked the Plan to reduce the cost share for the dental services. You say that you were overcharged for the 
dental servies. The Plan denied your request. The Plan says that the dental claims were processed correctly. 
 
We decided that the Plan has to pay for a limited oral evaluation (D0140) provided on April 9, 2021, a 
periodic oral evaluation (D0120) provided on July 6, 2021, and a periapical x-ray (D0220) provided on 
April 8, 2022. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for a dental exam was previously exhausted. 
Therefore, we decided that the Plan has to pay for a limited oral evaluation (D0140) provided on April 9, 2021, 
and a periodic oral evaluation (D0120) provided on July 6, 2021. 
 
According to the 2022 EOC, one periapical x-ray is covered every three years. Therefore, we decided that the 
Plan has to pay for a periapical x-ray (D0220) provided on April 8, 2022. 
 
We also decided that the Plan does not have to reduce the cost share for the fillings and crowns provided 
from July 31, 2020, to February 8, 2022, and does not have to pay for periapical x-rays provided on July 
31, 2020, August 4, 2020, and June 1, 2022, and a filling and crowns provided from February 22, 2022, to 
June 1, 2022. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for fillings and crowns provided in 2020. The contract also says that you must pay 20% 
coinsurance for fillings provided in 2021 and 2022.  
 
You have been asked to pay 50% coinsurance for the fillings and crowns received from July 31, 2020, to 
September 25, 2020. 
 
Date Code Allowed Amount Coinsurance 
July 31, 2020 D2393 $125 $62.50 
July 31, 2020 D2393 $125 $62.50 
August 4, 2020 D2332 $108 $54 
August 4, 2020 D2394 $137.83 $68.91 
September 2, 2020 D2740 $599.25 $299.62 September 25, 2020 D2740 $599.25 $299.62 
 
You have been asked to pay 20% coinsurance for the fillings received on May 11, 2021, and February 8, 2022. 
 
Date Code Allowed Amount Coinsurance 
May 11, 2021 D2331 $94.91 $18.98 
February 8, 2022 D2394 $142.23 $28.44 
February 8, 2022 D2393 $130.71 $26.14 
 
These items/services fall within the dental services benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan.  
 
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, certain limitations apply. Periapical x-
rays (D0220, D0230) are not among those covered under this benefit on date of service July 31, 2020, and 
August 4, 2020. The record shows your benefit for fillings was exhausted on date of service July 31, 2020. The 
record shows your benefit for crowns was exhausted on date of service September 2, 2020. According to the 
2022 EOC, periapical x-rays are covered once every three years. Therefore, the x-rays received on June 1, 
2022, are not covered. We decided that the Plan does not have to reduce the cost share for the fillings and 
crowns provided from July 31, 2020, to February 8, 2022, and does not have to pay for periapical x-rays 
provided on July 31, 2020, August 4, 2020, and June 1, 2022, and a filling and crowns provided from February 
22, 2022, to June 1, 2022. 
 
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.