Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to pay for one of the intraoral x-rays. We decided that the Plan does not have to pay for the problem focused limited oral evaluation, preventive procedure, endodontic procedure, adjunctive procedure, and non-intravenous conscious sedation.   You asked the Plan to pay for the problem focused limited oral evaluation, preventive procedure, endodontic procedure, adjunctive procedure, non-intravenous conscious sedation, and intraoral periapical x-rays. You say that the Plan sent you two referral sheets for providers that accepted your insurance. The Plan says that the preventive procedure, endodontic procedure, adjunctive procedure, and non-intravenous conscious sedation are not covered expenses under your plan. The Plan also says that your benefits for the problem focused limited oral evaluation and intraoral periapical x-rays have been satisfied and the frequency limitation has been exceeded.  We decided that the Plan has to pay for one of the intraoral x-rays.   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. You received a first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) which the Plan denied saying your intraoral x-rays benefit has been exhausted. The 2021 Evidence of Coverage says that intraoral x-rays are limited to one procedure code per calendar year. No documentation was submitted showing the Plan has already covered an intraoral x-ray during the 2021 benefit year. You reasonably believed one of the intraoral x-rays would be covered because the documentation does not show that this benefit has been exhausted. Therefore, we decided that the Plan has to pay for one of the intraoral x-rays.   We also decided that the Plan does not have to pay for the problem focused limited oral evaluation, preventive procedure, endodontic procedure, adjunctive procedure, and non-intravenous conscious sedation.  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 problem focused limited oral evaluation (D0140), unspecified preventive procedure (D1999), unspecified endodontic procedure (D3999), unspecified adjunctive procedure (D9999), and non-intravenous conscious sedation (D9248) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, preventive procedure, endodontic procedure, adjunctive procedure, and non-intravenous conscious sedation.  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.