Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical first x-ray 
(D0220). We also decided that the plan does not have to pay more for the extraction of an erupted tooth 
(D7210) for tooth number 2 and an intraoral  periapical x-ray (D0230) provided on October 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you informed the dentist that they took out the 
good tooth instead of the bad tooth on October 4, 2022. The Plan denied your request. The Plan says your 
benefit for a limited oral evaluation (D0140) and a periapical first x-ray (D0220) has already been exhausted. 
The Plan also says that the cost sharing for the extraction of an erupted tooth (D7210) for tooth number 2 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 this benefit includes a 
limited oral evaluation (D0140), but is limited to one every six months. This benefit also includes a periapical 
first x-ray (D0220) but is limited to one every three years. Your contract with the Plan also says that enrollees 
must pay 40% coinsurance for in-network comprehensive dental services, including oral surgery. Your contract 
with the Plan also says that enrollees must see an in-network dentist for coverage. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for a limited oral evaluation (D0140) and a periapical first x-ray (D0220) was exhausted on 
date of service August 11, 2022. 
 
You have also been asked to pay $56.36, which is 40% of the allowed amount for the extraction of an erupted 
tooth (D7210) for tooth number 2 ($140.91 allowed amount x 40% coinsurance = $56.36). The extraction of an 
erupted tooth (D7210) falls within the comprehensive dental services, including oral surgery benefit category. 
The record shows the Plan paid the allowed amount for an intraoral  periapical x-ray (D0230). The record 
shows that the enrollee saw an out-of-network provider. However, the Plan agreed to pay a portion of the 
allowed amounts for codes D72120 and D0230. The Plan is not liable to pay anything further for the cost of the 
out-of-network services in dispute. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140) and a periapical first x-ray (D0220). We also decided that the Plan does not have to pay 
more for the extraction of an erupted tooth (D7210) for tooth number 2 and an intraoral  periapical x-ray 
(D0230) provided on October 4, 2022.  
 
Your complaint about the potentially poor customer 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.