Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for the diagnostic consultation (D9310) and the second intraoral periapical x-ray (first image) (D0220) provided on May 25, 2021.
You asked the Plan to hold you harmless for the diagnostic consultation and x-ray. You say you asked the provider if these services would be covered on the date of service, but your questions were ignored. You cannot afford to pay for these services and thought they would be covered. The Plan denied your request. The Plan says that the diagnostic consultation is not a covered service. In addition, the intraoral x-ray was billed with the wrong code. D0220 may only be used once per date of service, as it is the code for the first/initial intraoral image. There is a separate code for additional images. The Plan has covered one of the x-rays billed on May 25, 2021, with code D0220, but the second cannot be covered as it was billed incorrectly. The Plan has also stated that they made multiple attempts to reach out to the office of the contracted provider in order to correct and verify the billed codes, but the provider's office did not return the Plan's calls. The Plan also wanted to clarify if D9310 is the correct code for the consultation, as there are other office visit and exam codes that may be covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. Medicare rules also say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code D0220 is intraoral - periapical first radiographic image. Additional images taken on the same day should be billed with code D0230: intraoral - periapical each additional radiographic image. You were referred for the diagnostic consultation and x-ray by a contract provider. Two intraoral x-rays were billed with code D0220, and the Plan paid for one of these x-rays. We find that CPT code D0220 is not supported in the record, as this code is only appropriate for one intraoral x-ray per date of service, and another code is to be used for additional images. We also found that file does not show that the Plan or provider provided notice that the diagnostic consultation would not be covered. The Plan does cover some dental office visits and exams under different codes. There is no documentation that you were notified that the specific kind of exam you were provided with was not a covered service, and it cannot be reasonably expected that you would know what type of exam you were provided with on the date in question.
The x-ray was billed with an improper code, and the diagnostic consultation that was billed to the Plan is not a covered service. The Plan does not have to pay for this care. However, you cannot be held liable for a billing error submitted by the provider and an office visit or consultation that may have been appropriate and covered under a different code. You were referred for these services by a Plan-contracted provider, and documentation does not show that you were given proper notice that these services would not be covered. Therefore, we decided that the Plan has to hold you harmless for the diagnostic consultation (D9310) and the second intraoral periapical x-ray (first image) (D0220) provided on May 25, 2021.
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.