Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay more for the one first intraoral periapical x-ray (D0220 x1), resin-based composite (D2394), and one surgical extraction (D7210 x1). We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), two additional first intraoral periapical x-rays (D0220 x2), and one additional surgical extraction (D7210).

You asked the Plan to pay for the problem focused limited oral evaluation (D0140), three first intraoral periapical x-rays (D0220 x3), resin-based composite (D2394), and two surgical extractions (D7210 x2) provided on December 2, 2019 by an out-of-network (OON) provider. You say that you paid up front in full to have this work done and are now being billed more money for these services. The Plan says that the problem focused limited oral evaluation is not a covered service, and your intraoral x-rays and extractions benefits have been exhausted. The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.

We decided that the Plan has to pay more for the one first intraoral periapical x-ray (D0220 x1), resin-based composite (D2394), and one surgical extraction (D7210 x1).

The Plan follows Medicare rules. Medicare rules say that the Plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits.

The record shows that you received these services from an out-of-network (OON) provider. The Plan contract says that you are responsible for a 0% coinsurance for intraoral x-rays received OON. The contract also says that you must pay a 55% coinsurance for both resin-based composites and extractions that are received OON. The Plan says that for services received OON, you must pay the difference between the provider's billed amount and the Plan's allowed amount. The 2019 Evidence of Coverage does not state that you may be balance billed for covered dental services that are received OON. You reasonably believed the one intraoral x-ray, one resin-based composite, and one surgical extraction would be covered up to the allowed amount in full, less the cost-sharing you are responsible for. Therefore, we decided that the Plan has to pay more for the one first intraoral periapical x-ray (D0220 x1), resin-based composite (D2394), and one surgical extraction (D7210 x1).

We also decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), two additional first intraoral periapical x-rays (D0220 x2), and one additional surgical extraction (D7210).

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, problem focused limited oral evaluation is not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received three first intraoral periapical x-rays (D0220 x3) on December 2, 2019, one of which was covered by the Plan, and your intraoral x-rays benefit had been exhausted.

The Plan contract clearly states that you are responsible for a 55% coinsurance for resin-based composites and extractions that are received OON. The contract also clearly states that extractions are limited to one procedure per calendar year. The record shows that you received two surgical extractions (D7210 x2) on December 2, 2019, one of which was covered by the Plan, and your extractions benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), two additional first intraoral periapical x-rays (D0220 x2), and one additional surgical extraction (D7210).

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.