Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for an intraoral - periapical first radiographic image (D0220), and an 
intraoral - periapical each additional radiographic image (D0230). We decided that the Plan does not have 
to pay for core buildup (D2950) for teeth numbers 8, 10, 11 and 12, a porcelain/ceramic crown (D2740) for 
teeth numbers 6, 7, 11, 12, and 13, and a porcelain/ceramic retainer crown (D6740).  
 
You asked the Plan to pay for an intraoral - periapical first radiographic image (D0220), an intraoral - 
periapical each additional radiographic image (D0230), core buildup (D2950) for teeth numbers 8, 10, 11 and 
12, a porcelain/ceramic crown (D2740) for teeth numbers 6, 7, 11, 12, and 13, and a porcelain/ceramic retainer 
crown (D6740) for tooth number 8 provided on July 29, 2022. You say that you fell, knocked out your teeth 
and received 18 stitches to your chin. You also say that because of the damage this accident caused to your 
mouth, chin and teeth, you are having to have a significant amount of dental work performed. The Plan says 
that your benefit for the requested services have already been exhausted. 
 
We decided that the Plan has to pay for an intraoral - periapical first radiographic image (D0220), and 
an intraoral - periapical each additional radiographic image (D0230).  
 
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 IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan failed to verify that the benefits for an intraoral - periapical first 
radiographic image (D0220), and the intraoral - periapical each additional radiographic image (D0230) were 
exhausted. The Plan only verified the crowns. Without evidence of the Plan having already provided coverage 
for intraoral radiographic images within the same calendar year, we cannot prove that those services have been 
exhausted. Therefore, we decided that the Plan has to pay for an intraoral - periapical first radiographic image 
(D0220), and an intraoral - periapical each additional radiographic image (D0230).  
 
We also decided that the Plan does not have to pay for core buildup (D2950) for teeth numbers 8, 10, 11 
and 12, a porcelain/ceramic crown (D2740) for teeth numbers 6, 7, 11, 12, and 13, and a 
porcelain/ceramic retainer crown (D6740). 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, coverage for codes D2950, D2740 and 
D6740 is limited to twice per calendar year. The record shows your benefit for the requested services was 
exhausted before the date of service in dispute. Therefore, we decided that the Plan does not have to pay for 
core buildup (D2950) for teeth numbers 8, 10, 11 and 12, a porcelain/ceramic crown (D2740) for teeth numbers 
6, 7, 11, 12, and 13, and a porcelain/ceramic retainer crown (D6740). 
 
  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.