Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reimburse for intravenous moderate (conscious) sedation/analgesia - each 
subsequent 15-minute increment (D9243) x4, reline complete maxillary denture (direct) (D5730) and 
alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310) 
x2. We decided that the Plan does not have to reimburse for comprehensive oral evaluation - new or established 
patient (D0150), cone beam CT capture and interpretation with field of view of both jaws; with or without 
cranium (D0367) and frenulectomy (D7960).  
 
You asked the Plan to reimburse for dental services provided on January 31, 2022, to February 7, 2022. You 
say that you feel you should be reimbursed for the services provided. You say that you don't think the provider 
sent the Plan all the correct information. The Plan says that the services provided have been denied correctly. 
 
We decided that the Plan has to reimburse for intravenous moderate (conscious) sedation/analgesia - 
each subsequent 15-minute increment (D9243) x4, reline complete maxillary denture (direct) (D5730) 
and alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant 
(D7310) x2.  
 
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. The rules also say that 
Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent 
Review Entity (IRE). 
 
The Plan states that payment for reline complete maxillary denture (direct) (D5730) and alveoloplasty in 
conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310) x2 is included in 
another procedure but has not indicated what procedure. The contract indicates that coverage of reline complete 
maxillary denture (direct) (D5730) is limited to once a year and is excluded within 6 months of the receipt of 
new dentures. The Plan has not provided evidence that you have previously received this service or dentures. 
The contract also indicates that alveoloplasty in conjunction with extractions - four or more teeth or tooth 
spaces, per quadrant (D7310) x2 is covered once per year per quadrant. The Plan has not indicated you have 
previously received this service. The Plan stated that you were not eligible for intravenous moderate 
(conscious) sedation/analgesia - each subsequent 15-minute increment (D9243) x4, but the contract states there 
is unlimited coverage for this service and does not indicate that it must be provided with covered services. 
 
We also decided that the Plan does not have to reimburse for extraction, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140) x10, comprehensive oral evaluation - new or established 
patient (D0150), cone beam CT capture and interpretation with field of view of both jaws; with or 
without cranium (D0367) and frenulectomy (D7960). 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. 
 
Your benefit for comprehensive oral evaluation - new or established patient (D0150) is allowed once every 
three plan years, records show this was exhausted on November 26, 2019. Cone beam CT capture and 
interpretation with field of view of both jaws; with or without cranium (D0367) and frenulectomy (D7960) are 
not covered benefits under your Plan. The Plan has paid the allowed amount for extraction, erupted tooth or 
exposed root (elevation and/or forceps removal) (D7140) x10, and you are responsible for the remaining 
amount. Therefore, we decided that the Plan does not have to reimburse for extraction, erupted tooth or 
exposed root (elevation and/or forceps removal) (D7140) x10, comprehensive oral evaluation - new or 
established patient (D0150), cone beam CT capture and interpretation with field of view of both jaws; with or 
without cranium (D0367) and frenulectomy (D7960). 
 
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.