Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation - 
new or established patient (D0150), intraoral - complete series of radiographic images (D0210), 2D oral/facial 
photographic image obtained intra-orally or extra-orally (D0350),  detailed and extensive oral evaluation - 
problem focused, by report (D0160), diagnostic casts (D0470), cone beam computed tomography (CT) capture 
and interpretation with field of view of both jaws; with or without cranium (D0367), extraction, erupted tooth 
or exposed root (elevation and/or forceps removal) (D7140), and local anesthesia in conjunction with operative 
or surgical procedures (D9215) provided March 10, 2021, through March 28, 2021.  
You asked the Plan to provide additional payment for the dental services. You say that you would like 
reimbursement for these services. The Plan denied your request. The Plan says the claims have been processed 
correctly. 
 
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 covers one complete 
series of x-rays every five years and two oral exams per year with a $0 copayment and tooth extractions with 
50% coinsurance. If your dental services are performed by a dentist outside of the Plans dental network, you 
will be responsible for paying the difference between the dentists fees and the Plans dental fee schedule. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that they have covered 
100% of the allowed amount for the complete series of x-rays and 50% of the allowed amount for the 
extraction. You are responsible for 50% coinsurance for the extraction. Additionally, you are responsible for 
the difference between the allowed amount and the total cost billed by the provider for the complete series of x-
rays and tooth extraction because the services were received out-of-network. The Plan also provided 
documentation showing that oral exams were previously covered on February 1, 2021, and March 1, 2021.  
Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral 
exam has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the diagnostic 
casts, 2d oral/facial photographic image, problem focused extensive oral evaluation, cone beam CT image and 
local anesthesia are not among those covered services. Therefore, we decided that the Plan does not have to 
provide additional payment for the comprehensive oral evaluation - new or established patient (D0150), 
intraoral - complete series of radiographic images (D0210), 2D oral/facial photographic image obtained intra-
orally or extra-orally (D0350),  detailed and extensive oral evaluation - problem focused, by report (D0160), 
diagnostic casts (D0470), cone beam computed tomography (CT) capture and interpretation with field of view 
of both jaws; with or without cranium (D0367), extraction, erupted tooth or exposed root (elevation and/or 
forceps removal) (D7140), and local anesthesia in conjunction with operative or surgical procedures (D9215) 
provided March 10, 2021, through March 28, 2021.