Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to provide reimbursement for the oral exam (D0120), the bitewing x-rays 
(D0274), the periodontal scaling and root planing provided for the upper and lower left quadrants 
(D4341), and the retainer crown for tooth #4. We decided that the Plan does not have to provide 
reimbursement for the periodontal scaling and root planing for the upper and lower right quadrants (D4341).  
 
You asked the Plan to provide reimbursement for the multiple dental services provided on June 23, 2022, with 
payment made up front. You say that you were told that everything would be covered 100% by the Plan. The 
Plan says that the correct amounts were paid directly to the provider for these services. Therefore, the Plan 
cannot make any additional payments. 
 
We decided that the Plan has to provide reimbursement for the oral exam (D0120), the bitewing x-rays 
(D0274), the periodontal scaling and root planing provided for the upper and lower left quadrants 
(D4341), and the retainer crown for tooth #4.  
 
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. We find that the Plan has not met its obligation to ensure its network providers 
only accept payment for the Plan-allowed amount for covered services. The network provider collected 
payment up front for the full retail amount for all the services rendered. The provider then submitted a claim 
for only a portion of the services rendered for which the Plan paid only the allowed amount. We sent a request 
to the Plan to ask if it has required the provider to refund you the excess charges between the allowed amount 
and the amount you originally paid for the covered services. As such, we find that the Plan must refund you the 
difference and may seek to recoup those charges directly from the provider. This includes the full $165.91 
amount for the scaling and root planing of the lower left quadrant (D4341) for which the Plan lowered the 
reimbursement to that for D4342. The Plan has not provided any justification to support that reduction to a 
lower amount, and you paid the entire amount for D4341 up front.  
 
Based on a comparison between the billed (paid by you) charges and the allowed charges, we find that the 
provider collected an excess of $371.33 from you for the covered services it billed to the Plan.  The Plan must remit this amount to you. Therefore, we decided that the Plan has to provide reimbursement for 
the oral exam (D0120), the bitewing x-rays (D0274), the periodontal scaling and root planing provided for the 
upper and lower left quadrants (D4341), and the retainer crown for tooth #4.  
 
We also decided that the Plan does not have to provide reimbursement for the periodontal scaling and 
root planing for the upper and lower right quadrants (D4341). 
 
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. 
 
The Plan submitted evidence showing that payment was previously made for scaling and root planing for these 
two quadrants on September 30, 2020. Since these services were provided less than three years after this date, 
the benefit is exhausted, and these services are not covered on the date of service at issue. Therefore, we 
decided that the Plan does not have to provide reimbursement for the periodontal scaling and root planing for 
the upper and lower right quadrants (D4341). 
 
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.