Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral exam (D0140), intraoral x-ray (D0220) and incision and drainage of abscess (D7510) provided on June 30, 2021, and the extraction (D7140) provided on July 5, 2021, by an out-of-network provider.  You asked the Plan to pay for the dental services. You say that more should be paid for these services and you feel the claims should be reprocessed. The Plan denied your request. The Plan says the incision and drainage of abscess and the limited oral exam are not covered services under your dental benefit. The intraoral x-ray and extraction were processed correctly at the out-of-network rate, and you are responsible for the remainder of the cost.  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 Plan does not cover services that are not listed in the dental benefits chart.  The rules also say that 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 intraoral x-rays and 55% coinsurance for extractions when these services are received out-of-network. If you see a network dentist, you cannot be billed more than the allowed 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.  Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral exam and incision and drainage of abscess are not among those covered under this benefit. Therefore, the Plan does not have to pay for these services based on your contract.  The provider billed $35 for the intraoral x-ray provided on June 30, 2021. The Plan's allowed amount for this x-ray is $15. This is the amount an in-network provider would accept as full payment for this service, but out-of-network providers do not have this agreement with the Plan and are permitted to ask for payment up to the full amount billed. You are responsible for the difference between the provider's billed amount and the maximum amount the Plan will pay. ($35 - $15 = $20). In addition, you are responsible for 50% coinsurance on the Plan's allowed cost for intraoral x-rays received out-of-network. ($15 x 50% coinsurance = $7.50). This means that you are responsible for $27.50 for the x-ray, and the Plan must pay $7.50. Documentation shows that the Plan has paid $7.50 for this service. This means you have been asked to pay the correct amount for this service based on the Plan's contract.  The provider billed $183 for the extraction provided on July 5, 2021. The Plan's allowed amount for the extraction is $78. You are responsible for the difference between the amount the out-of-network provider bills and the Plan's allowed amount for the service. ($183 - $78 = $105). The contract also states that you are responsible for 55% coinsurance for extractions received from an out-of-network provider. ($78 allowed amount x 55% coinsurance = $42.90). This means the Plan is responsible for $35.10 and you are responsible for $147.90. Documentation shows that the Plan has paid the required amount for this service, and you have been asked to pay the correct amount based on your contract with the Plan. This cost-sharing is a contractual obligation that 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 limited oral exam (D0140), intraoral x-ray (D0220) and incision and drainage of abscess (D7510) provided on June 30, 2021, and the extraction (D7140) provided on July 5, 2021, by an out-of-network provider.