Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bone graft for ridge preservation (D8953) and extraction (D7140) provided on January 5, 2021, and the placement of implant (D6010) provided on April 15, 2021.  You asked the Plan to pay for the bone graft and implant placement. You say that the bone graft was necessary to have the implant done and should be a covered service. You also say you were charged more than you should have been for the implant, as this service is covered at 50% after you meet your $100 dental deductible. The Plan denied your request. The Plan says this claim was processed in accordance with your contract. Bone grafts are not covered by your dental benefit. The implant is covered, but you chose to use an out-of-network provider for services. You are responsible for 50% coinsurance of the covered plan allowance for implant services, and you may be asked to pay more by the out-of-network provider.  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 dental bone grafts. 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 on the Plan's covered allowance after your $100 deductible is met for major dental services. This includes extractions and implants. You will save more when you receive care from an in-network dental provider. You can get care from an out-of-network provider, but you may pay more.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested bone graft for ridge preservation is not among those covered under this benefit. You are responsible for the full cost of this service.  The provider billed a total of $450 for the extraction provided on January 5, 2021. The Plan's allowed cost for this service is $57. You are responsible for 50% coinsurance on this covered allowance after your $100 deductible is met. Documentation shows that you had not met your deductible at the time of services, and the full $57 allowed cost was applied to your deductible. You are also responsible for the difference between the amount the provider billed the Plan and the Plan's allowed cost because you used an out-of-network provider. This means you are responsible for the full $450 for the extraction and have been asked to pay the correct amount based on your contract with the Plan.  The provider billed $2,600 for the implant placement provided on April 15, 2021. The Plan's allowed cost for this service is $904.63. You are responsible for 50% coinsurance on this covered allowance after your $100 deductible is met. You had $43 remaining to meet your deductible. Then you are responsible for 50% of the allowed cost. ($904.63 x 50% coinsurance = $452.32). Because you used an out-of-network provider, you are also responsible for the difference between the amount the provider billed and the Plan's allowed cost. ($2,600 - $904.63 = $1,695.37). The Plan has paid their share of the cost, and you are responsible for the remaining $2,147.68 ($452.31 coinsurance + $1,695.37 out-of-network price difference = $2,147.68.) 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 pay any additional amount for the bone graft for ridge preservation (D8953) and extraction (D7140) provided on January 5, 2021, or for the placement of implant (D6010) provided on April 15, 2021.