Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance endodontic therapy, anterior tooth (D3310), 
intraoral - periapical first radiographic image (D0220) and panoramic radiographic image (D0330). We also 
decided that the Plan does not have to pay for the cone beam CT image capture  (D0380), pulp vitality tests 
(D0460), consultation - diagnostic service (D9310), and prefabricated post and core in addition to crown 
(D2954) provided on October 6, 2022, and October 17, 2022. 
 
You asked the Plan to waive the coinsurance endodontic therapy, anterior tooth (D3310), intraoral - periapical 
first radiographic image (D0220) and panoramic radiographic image (D0330). You also asked the Plan to pay 
for the cone beam CT image capture  (D0380), pulp vitality tests (D0460), consultation - diagnostic service 
(D9310), and prefabricated post and core in addition to crown (D2954).The Plan denied your request. The Plan 
says the coinsurance was appropriately applied to the codes represented by D3310, D0220, and D0330. The 
Plan says that cone beam CT image capture  (D0380), pulp vitality tests (D0460), consultation - diagnostic 
service (D9310), and prefabricated post and core in addition to crown (D2954). are not covered under the 
enrollees benefits. 
 
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 the dental codes represented by D0220, D0330, and a 75% coinsurance for the D3310 provided 
out-of- network. 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. 
 
You have been asked to pay a 50% coinsurance for the panoramic radiographic image (D0330), intraoral - 
periapical first radiographic image (D0220), and a 75% coinsurance for the endodontic therapy, anterior tooth 
(D3310). These services fall within the preventive and diagnostic dental services provided out-of-network 
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 endodontic therapy, anterior tooth 
(D3310), intraoral - periapical first radiographic image (D0220) and panoramic radiographic image (D0330). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam CT image capture  
(D0380), pulp vitality tests (D0460), consultation - diagnostic service (D9310), and prefabricated post and core 
in addition to crown (D2954) are not covered under this benefit. Therefore, we decided the Plan does not have 
to pay for the cone beam CT image capture  (D0380), pulp vitality tests (D0460), consultation - diagnostic 
service (D9310), and prefabricated post and core in addition to crown (D2954) provided on October 6, 2022 
and October 17, 2022.