Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the problem focused limited oral evaluation (D0140), apicoectomy 
(D3425), and retrograde filling (D3430). We decided that the Plan does not have to pay for the cone beam 
computed tomography (CT) capture and interpretation (D0367), and drugs or medicaments dispensed in the 
office for home use (D9630).  
 
You asked the Plan to pay for the problem focused limited oral evaluation (D0140), cone beam computed 
tomography (CT) capture and interpretation (D0367), apicoectomy (D3425), retrograde filling (D3430), and 
drugs or medicaments dispensed in the office for home use (D9630) provided on March 18, 2022. You say that 
you had the abscess and issues that you were suffering from fixed. You also say that you would like to see if 
these services can be covered under your medical insurance. The Plan says that the provider stated these codes 
are dental for the services that were provided. 
 
We decided that the Plan has to pay for the problem focused limited oral evaluation (D0140), 
apicoectomy (D3425), and retrograde filling (D3430).  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the Independent Review Entity (IRE) information regarding its 
decision to deny coverage or payment. 
 
We looked at the file and Medicare rules. The record shows that you received a problem focused limited oral 
evaluation (D0140), apicoectomy (D3425), and retrograde filling (D3430) which the Plan denied. The 
Evidence of Coverage states oral exams are limited to up to 2 visits per calendar year, and root canals are 
covered once per tooth every 7 years. The Plan did not provide any documentation showing your oral exams 
benefit, or your root canal benefit for tooth #2 had been exhausted prior to this date of service. The 
apicoectomy (D3425) and retrograde filling (D3430) were both part of the root canal procedure that was 
performed on tooth #2. You reasonably believed these services would be covered because they are listed as 
covered services. Based on this information, we decided that the Plan's rules for coverage of the problem 
focused limited oral evaluation (D0140), apicoectomy (D3425), and retrograde filling (D3430) have been met. 
Therefore, we decided that the Plan has to pay for the problem focused limited oral evaluation (D0140), 
apicoectomy (D3425), and retrograde filling (D3430).  
 
We also decided that the Plan does not have to pay for the cone beam computed tomography (CT) 
capture and interpretation (D0367), and drugs or medicaments dispensed in the office for home use 
(D9630). 
 
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. 
 
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. Additionally, these services do not qualify for coverage under your 
medical benefits. Therefore, we decided that the Plan does not have to pay for the cone beam computed 
tomography (CT) capture and interpretation (D0367), and drugs or medicaments dispensed in the office for 
home use (D9630). 
 
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. 
 
Your complaint about the first root canal being performed on the incorrect tooth is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.