Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150), bitewing x-rays 
(D0274), panoramic x-ray (D0330) and dental cleaning (D1110) provided on November 19, 2021, by an out-
of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you were told this provider could take your 
insurance, and you do not understand why you have such a high bill for these services. The Plan denied your 
request. The Plan says the panoramic x-ray is not a covered service under your benefit. The other services are 
covered, but you are responsible for 50% coinsurance for covered services performed by an out-of-network 
provider. In addition, out-of-network provider are allowed to bill you for any amount that exceeds the Plan's 
allowed price for covered services. This claim was 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, panoramic x-rays are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray 
(D0330) provided on November 19, 2021. 
 
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 50% 
coinsurance for covered dental services performed by an out-of-network provider. If you see a network dentist, 
you cannot be billed more than the Plans rate for covered services. Benefits received out-of-network are 
subject to any in-network benefit maximums, limitations, and/or exclusions. You may be billed by the out-of-
network provider for any amount greater than the payment made by the Plan to the provider. 
 
The provider billed the Plan a total of $347 for the comprehensive exam, bitewing x-rays and cleaning. The 
Plans allowed cost for these services is $83. This is the amount that an in-network provider would accept as 
full payment for a cleaning, bitewing x-rays and comprehensive exam. Out-of-network providers do not have 
this agreement with the Plan and are allowed to bill you the difference between what was billed and the Plans 
allowed cost for services ($347 - $83 = $264). In addition, you are responsible for 50% coinsurance for these 
services, which is always calculated from the Plans allowed rate ($83 x 50% coinsurance = $41.50). You have 
been asked to pay $305.50 for these services ($264 + $41.50) and an additional $159 for the non-covered 
panoramic x-ray ($305.50 + 159 = $464.50). 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 pay any additional amount for the 
comprehensive oral exam (D0150), bitewing x-rays (D0274) and dental cleaning (D1110) provided on 
November 19, 2021, by an out-of-network provider.