Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance applied to the bitewing x-rays (D0270), an 
intraoral  periapical first radiographic image (D0220), and an extraction of an erupted tooth requiring removal 
of bone and/or sectioning of tooth (D7210) provided on September 26, 2022. We also decided that the Plan 
does not have to pay for a limited oral evaluation  problem focused (D0140), intraoral  periapical each 
additional (D0230), cone beam CT capture and interpretation with field of view of both jaws( D0367), bone 
replacement graft for ridge preservation (D7953), and guided tissue regeneration (D4266) provided on 
September 26, 2022. 
 
You asked the Plan to waive the coinsurance applied to the bitewing x-rays, the first intraoral periapical 
radiographic image, and the extraction. You also asked the Plan to pay for codes  D0140, D0230, D0367, 
D7953 and D4266. You say that you needed to be seen for emergency services. You also say that you believe 
the claim denied because you were seen by an out-of-network dentist. The Plan denied your request. The Plan 
says the coinsurance was appropriately applied to the bitewing x-ray, the first intraoral periapical radiographic 
image, and the extraction provided. The Plan says that the dental services represented by codes D0140, D0367, 
D7953 and D4266 are not covered under the dental benefits. The Plan also says that the additional intraoral 
periapical radiographic image (D0230) was not covered because your benefit for this service had been 
exhausted.  
 
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. 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 bitewing x-
rays and intraoral periapical radiographic imaging provided out-of-network. Your contact with the Plan clearly 
says that you must pay a 55% coinsurance for extractions provided out-of-network. 
 
You have been asked to pay a 50% coinsurance for the bitewing x-rays and the first intraoral periapical 
radiographic image. You have also been asked to pay a 55% coinsurance for the extraction. These services 
were received from an out-of-network provider. 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 
applied to the bitewing x-rays (D0270), the intraoral  periapical first radiographic image (D0220), and the 
extraction erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on September 
26, 2022. 
 
The Plan contract says that 1 procedure code for intraoral periapical x-rays is covered per calendar year. The 
record shows that the Plan paid for an intraoral periapical x-ray provided on September 26, 2022. This 
exhausted your benefit for intraoral periapical x-rays. Therefore, we decided that the Plan does not have to pay 
for the additional intraoral periapical radiographic image (D0230) provided on September 26, 2022.  
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services represented by 
codes D0140, D0367, D7953 and D4266 are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation  problem focused (D0140), cone beam 
CT capture and interpretation with field of view of both jaws (D0367), bone replacement graft for ridge 
preservation (D7953), and guided tissue regeneration (D4266) provided on September 26, 2022.