Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a limited oral evaluation - problem 
focused (D0140), intraoral - periapical first radiographic image (D0220), extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210), comprehensive oral evaluation - new or established 
patient (D0150), intraoral - complete series of radiographic images (D0210), and prophylaxis - adult (D1110) 
provided on July 25, 2022, to October 5, 2022. 
 
 You asked the Plan to waive the coinsurance for the dental services represented by codes D0140, D0220, 
D7210, D0150, D0210, and D1110. You say that you were not aware that the dentist was out-of-network. You 
also say that the secretary at the office informed you the provider accepted your insurance. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
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 a limited oral evaluation - problem focused (D0140), comprehensive oral evaluation - new or 
established patient (D0150), and prophylaxis - adult (D1110) provided out-of-network (OON). The Plan 
contract also says that enrollees must pay a 50% coinsurance for intraoral - periapical first radiographic image 
(D0220), and intraoral - complete series of radiographic images (D0210) provided OON. The Plan contract also 
says that a enrollees must pay a 55% coinsurance for an extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210). 
 
You have been asked to pay a 50% coinsurance for the dental services represented by codes D0140, D0220, 
D0150, D0210, and D1110. You also have been asked to pay a 55% coinsurance for the dental service code 
represented by D7210. The limited oral evaluation - problem focused (D0140), comprehensive oral evaluation - 
new or established patient (D0150), and prophylaxis - adult (D1110) falls under the exams benefit category. 
The intraoral - periapical first radiographic image (D0220), and intraoral - complete series of radiographic 
images (D0210) falls under the intraoral x-rays benefit category. The extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210) falls under the extractions 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. Therefore, we decided that 
the Plan does not have to waive the coinsurance for a limited oral evaluation - problem focused (D0140), 
intraoral - periapical first radiographic image (D0220), extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210), comprehensive oral evaluation - new or established patient (D0150), 
intraoral - complete series of radiographic images (D0210), and prophylaxis - adult (D1110) provided on July 
25, 2022, to October 5, 2022.