Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper and lower dentures (D5110, D5120) and 
the unspecified removable prosthodontic procedures (D5899) provided on January 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were referred to this provider and did not 
realize they were out-of-network. The Plan denied your request. The Plan says you are responsible for 75% 
coinsurance for complete dentures received out-of-network. In addition, out-of-network providers are allowed 
to bill you for the difference between the billed amount and the Plan's payment for services. The dentures are 
covered and have been processed in accordance with your out-of-network benefits. In addition, the unspecified 
removable prosthodontic procedures are not covered by your dental benefit. 
 
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 Plan does not cover dental 
services which are not listed in the dental benefits chart in the contract.  
 
In addition, 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 75% coinsurance for complete dentures received from an out-of-network provider. Network 
dentists have agreed to provide services at a negotiated rate. If you see a network dentist, you cannot be billed 
more than that rate. Benefits received out-of-network are subject to any in-network benefit maximums, 
limitations and/or exclusions. You may be billed by the out-of-network provider for any amount greater than 
the payment made by the Plan to the provider. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested unspecified removable 
prosthodontic procedures are not among those covered under this benefit.  
 
The record shows that the provider billed the Plan $1,299 for each of the complete dentures. The Plans 
allowed amount for these services is $751 per denture. This is the amount that an in-network provider has 
agreed to accept as full payment for these services; however, out-of-network dentists do not have this 
agreement with the Plan and are allowed to bill you the difference between what they bill and the Plans price 
($1,299 - $751 = $548 per denture). In addition, you are responsible for 75% coinsurance on the Plans allowed 
amount for each denture. ($751 x 75% coinsurance = $563.25 per denture). This means 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. 
 
Therefore, we decided that the Plan does not have to pay for the complete upper and lower dentures (D5110, 
D5120) and the unspecified removable prosthodontic procedures (D5899) provided on January 13, 2022.  
 
Your complaint about potential misinformation from a Plan representative is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.