Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adding tooth to existing partial denture (D5650) and a 
surgical extraction (D7210) for tooth #12, #14, and #15 provided on April 14, 2022. You also asked the Plan to 
waive the coinsurance for the fillings (D2331 and D2332) and the extractions (D7140) for tooth #14, #15, #22, 
#23, #24, #25, #26, and #27 provided on March 7, 2022, March 30, 2022, April 14, 2022, and June 27, 2022. 
 
You asked the Plan to pay and waive the coinsurance for the dental services. You say that the dental services 
you received were not good and you would like to have the coinsurance waived. The Plan denied your request. 
The Plan says the denial of payment for these services is correct, because adding tooth to existing partial 
dentures and surgical extractions are not covered by the Plan. Also, the proper cost share was applied to all 
covered services. 
 
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 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 a 50% 
coinsurance for class 2 basic services. On March 7, 2022, the first total allowed amount was $134 with a 
coinsurance of $67 ($134 total amount x 50% coinsurance). The second total allowed amount was $134 with a 
coinsurance of $67 ($134 total amount x 50% coinsurance). The third allowed amount was $134 with a 
coinsurance of $67 ($134 total amount x 50% coinsurance). On March 30, 2022, the first total allowed amount 
was $134 with a coinsurance of $67 ($134 total amount x 50% coinsurance). The second total allowed amount 
was $134 with a coinsurance of $67 ($134 total amount x 50% coinsurance). The third total allowed amount 
was $134 with a coinsurance of $67 ($134 total amount x 50% coinsurance). The fourth total allowed amount 
was $134 with a coinsurance of $67 ($134 total amount x 50% coinsurance). The fifth total allowed amount 
was $164 with a coinsurance of $82 ($164 total amount x 50% coinsurance). On April 14, 2022, the first total 
allowed amount was $110 with a coinsurance of $55 ($110 total amount x 50% coinsurance). The second total 
allowed amount was $110 with a coinsurance of $55 ($110 total amount x 50% coinsurance). On June 27, 
2022, the first total allowed amount was $134 with a coinsurance of $67 ($134 total amount x 50% 
coinsurance). The second total allowed amount was $134 with a coinsurance of $67 ($134 total amount x 50% 
coinsurance). The total coinsurance amount for all dates of service was $795 ($67 coinsurance + $67 
coinsurance + $67 coinsurance + $67 coinsurance + $67 coinsurance + $67 coinsurance + $67 coinsurance + 
$82 coinsurance + $55 coinsurance + $55 coinsurance + $67 coinsurance + $67 coinsurance). 
  
You have been asked to pay $795 coinsurance for the dental services. This item/service falls within the dental 
services benefit category. This means that 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the adding tooth to existing 
partial dentures and surgical extractions are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for adding tooth to existing partial denture (D5650) and a surgical extraction 
(D7210) for tooth #12, #14, and #15 provided on April 14, 2022. We also decided that the Plan does not have 
to waive the coinsurance for the fillings (D2331 and D2332) and the extractions (D7140) for tooth #14, #15, 
#22, #23, #24, #25, #26, and #27 provided on March 7, 2022, March 30, 2022, April 14, 2022, and June 27, 
2022.  
  Your complaint about your experience with the provider and their quality of service 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.