Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam, cleaning (D1110) and complete series of x-rays (D0210) provided on June 8, 2021.

You asked the Plan to pay for the dental services. You say that you saw this dentist because your previous dentist's office closed. You feel these services should be covered. The Plan denied your request. The Plan says this claim was processed in accordance with your contract. Your dental benefit does not cover complete series of x-rays. You are covered for one comprehensive oral evaluation every three years, but you previously had a comprehensive exam in August 2019, which is less than three years before the date in question. The cleaning has been covered; however, these services were received out-of-network. You are therefore responsible for 50% coinsurance for the cleaning, as well as the difference between the amount the provider billed for the service and the Plan's allowed amount.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The rules also 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 50% coinsurance for covered dental services received out-of-network. 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 for covered services. If you receive covered services out-of-network, 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 complete series of x-rays are not among those covered under this benefit. In addition, only one comprehensive or periodontal oral exam may be covered every three years. Documentation shows that you had a previous comprehensive oral exam less than three years before the date in question. Therefore, you benefit for this type of exam was exhausted on the date in question.

The cleaning is a covered service. The provider billed $88 for this service. The Plan's allowed amount for a dental cleaning is $45. This is the amount that a network provider would accept as full payment, but out-of-network providers do not have this agreement and are allowed to ask you to pay the remaining billed amount. You are responsible for the difference between the Plan's allowed amount and the amount the provider billed ($88 - $45 = $43). You are also responsible for 50% coinsurance on the allowed amount for covered out-of-network dental care. ($45 x 50% coinsurance = $22.50). Documentation shows that the Plan has paid the required $22.50 for this service, and you are responsible for the remaining cost of $65.50. This means you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay any additional amount for the comprehensive oral exam, cleaning (D1110) and complete series of x-rays (D0210) provided on June 8, 2021.