Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the periodontal maintenance (D4910) and topical application of 
fluoride varnish (D1206). We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test 
(D0431).  
 
You asked the Plan to pay for the periodontal maintenance (D4910), topical application of fluoride varnish 
(D1206), and adjunctive pre-diagnostic test (D0431) provided on March 17, 2022. You say that you are allergic 
to the treatment used for a deep cleaning. You also say that you have always had periodontal cleanings done 
with no problem and they were never denied. The Plan says that periodontal maintenance is only allowed when 
you have had a deep cleaning done in the past, and your records do not show that you have had a deep 
cleaning. The Plan also says that topical application of fluoride varnish and adjunctive pre-diagnostic test are 
not covered by the Plan. 
 
We decided that the Plan has to pay for the periodontal maintenance (D4910) and topical application of 
fluoride varnish (D1206).  
 
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. 
 
We looked at the file and Medicare rules. The 2022 Evidence of Coverage (EOC) states periodontics are 
covered every 6 to 36 months, and the ranges relate to the frequency of the procedures performed. The EOC 
also indicates that fluoride treatments are covered once per calendar year. The contract does not clearly state 
any benefit limitations for periodontal maintenance, and does not clearly specify what type(s) of fluoride 
treatments are covered. The Plan contract also does not refer you to any other documents to check for criteria 
or to see if these services were covered prior to receiving these services. You reasonably believed the 
periodontal maintenance and topical application of fluoride varnish would be covered because both 
periodontics and fluoride treatments are listed as covered services. Based on this information, we decided that 
the Plan's rules for coverage of the periodontal maintenance (D4910) and topical application of fluoride varnish 
(D1206) have been met. Therefore, we decided that the Plan has to pay for the periodontal maintenance 
(D4910) and topical application of fluoride varnish (D1206).  
 
We also decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431). 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic test (D0431). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.