Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), 
comprehensive oral evaluation (D0150), and prophylaxis (D1110), or pay more for the two resin-based 
composites of one surface (D2330 x2), resin-based composite of two surfaces (D2331), resin-based composite 
of three surfaces (D2332), three resin-based composites of four surfaces (D2335 x3), four simple extractions 
(D7140 x4), core buildup, including any pins when required (D2950), and crown (D2750) provided from April 
13, 2021, to November 23, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, comprehensive oral evaluation, and 
prophylaxis, and to pay more for the resin-based composites, simple extractions, core buildup, and crown. You 
say that the alleged debts are not valid and should be erased from your dental records. The Plan denied your 
request. The Plan says problem focused limited oral evaluation is not a covered service under your preventive 
and comprehensive dental benefits. The Plan says that your benefit maximums have been met for the 
comprehensive oral evaluation and prophylaxis. The Plan also says that a 50% coinsurance was correctly 
applied for the resin-based composites, simple extractions, core buildup, and crown. 
 
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, problem focused limited oral 
evaluation (D0140) is not among those covered under this benefit. The Plan contract says that comprehensive 
oral evaluation (D0150) is limited to once every 36 months. The record shows that you received a 
comprehensive oral evaluation (D0150) on March 10, 2021 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. The contract also says that prophylaxis (D1110) is allowed two times every year. 
The record shows that you received a prophylaxis (D1110) on February 4, 2021, and on August 6, 2021 and 
your prophylaxis (D1110) benefit has been exhausted. The Plan contract also says that you are responsible for a 
50% coinsurance for extractions, fillings, onlays, crowns, and bridges. Therefore, we decided that the Plan does 
not have to pay for the problem focused limited oral evaluation (D0140), comprehensive oral evaluation 
(D0150), and prophylaxis (D1110), or pay more for the two resin-based composites of one surface (D2330 x2), 
resin-based composite of two surfaces (D2331), resin-based composite of three surfaces (D2332), three resin-
based composites of four surfaces (D2335 x3), four simple extractions (D7140 x4), core buildup, including any 
pins when required (D2950), and crown (D2750) provided from April 13, 2021, to November 23, 2021.  
 
Your complaint about the dental practice violating the reasonable predictable expectations which you are 
entitled to 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.