Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) and the dental cleaning 
provided (D1110) on June 8, 2022. We also decided that the Plan does not have to pay for the intra-oral 
complete series of radiographic images (D0210), unspecified preventive procedure, by report (D1999), 
porcelain/ceramic retainer crowns (D6740 x 3), core buildups, including any pins when required (D2950 x 4), 
porcelain/ceramic pontics (D6245 x 3), and the porcelain/ceramic crowns (D2740 x 2) provided from June 8, 
2022, through September 16, 2022.  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plans 
denial for payment. The Plan says that these services are not covered.  
 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) and the dental 
cleaning (D1110) provided on June 8, 2022. 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. These services provided are indicated as covered benefits 
in the Plans contract. However, we are unable to determine if a contracted provider rendered these services as 
this information has not been submitted in the case file. The Plan has not substantiated their denial; therefore, 
we must find in your favor. Therefore, we decided that the Plan has to pay for the comprehensive oral 
evaluation (D0150) and the dental cleaning (D1110) provided on June 8, 2022.  
 
We also decided that the Plan does not have to pay for the intra-oral complete series of radiographic 
images (D0210), unspecified preventive procedure, by report (D1999), porcelain/ceramic retainer crowns 
(D6740 x 3), core buildups, including any pins when required (D2950 x 4), porcelain/ceramic pontics 
(D6245 x 3), and the porcelain/ceramic crowns (D2740 x 2) provided from June 8, 2022, through 
September 16, 2022. The Plan contract indicates that these services are not a covered benefit under the 
supplemental dental benefit. Additionally, dental crowns are a covered benefit; however, the record shows that 
these items were provided by a non-contracted dental provider. Items/services rendered by a non-contracted 
provider are not covered. Therefore, we decided that the Plan does not have to pay for the intra-oral complete 
series of radiographic images (D0210), unspecified preventive procedure, by report (D1999), porcelain/ceramic 
retainer crowns (D6740 x 3), core buildups, including any pins when required (D2950 x 4), porcelain/ceramic 
pontics (D6245 x 3), and the porcelain/ceramic crowns (D2740 x 2) provided from June 8, 2022, through  
September 16, 2022. 
 
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.