Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to hold you harmless for the scaling in presence of generalized moderate or severe gingival inflammation. We decided that the Plan does not have to pay for the topical application of fluoride varnish, gingival irrigations, and drugs or medicaments.
You asked the Plan to pay for the scaling in presence of generalized moderate or severe gingival inflammation. You say that you would like these services to be covered either in full or at least 50% under the comprehensive dental benefits. The Plan says that these services are not covered.
We decided that the Plan has to hold you harmless for the scaling in presence of generalized moderate or severe gingival inflammation.
The Plan follows Medicare rules. Medicare rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. The Medicare rules also say that services and referrals obtained from a plan provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service. The file shows that you received a scaling in presence of generalized moderate or severe gingival inflammation (D4346). The 2021 Evidence of Coverage states that periodontic procedures, including root planing and scaling, are covered benefits. The contract does not clearly state which dental codes are covered under this benefit. You reasonably believed this service would be covered under the comprehensive dental services with the maximum allowance of $3,000 with a 50% coinsurance because the contract does list scaling as a covered service. Therefore, we decided that the Plan has to hold you harmless for the scaling in presence of generalized moderate or severe gingival inflammation.
We also decided that the Plan does not have to pay for the topical application of fluoride varnish, gingival irrigations, and drugs or medicaments.
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 requested items or services are not among those covered under this benefit.
The record shows that you signed a consent for treatment acknowledging that you agreed to be responsible for all services rendered on your behalf. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish, gingival irrigations, and drugs or medicaments.
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.