Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the inhalation of nitrous oxide/analgesia, anxiolysis (D9230). We 
decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) or pay more 
for the extraction (D7210).  
 
You asked the Plan to pay for the problem focused limited oral evaluation (D0140) and inhalation of nitrous 
oxide/analgesia, anxiolysis (D9230), and to pay more for the extraction (D7210). You say that you thought a 
Plan representative told you that you had 2 free cleanings per year, and 2 tooth extractions per year, and after 
that you would have to pay for half of the procedure. The Plan says that the problem focused limited oral 
evaluation and inhalation of nitrous oxide/analgesia, anxiolysis are not covered benefits. The Plan also says that 
you are responsible for a 50% coinsurance for the extraction. 
 
We decided that the Plan has to pay for the inhalation of nitrous oxide/analgesia, anxiolysis (D9230).  
 
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 inhalation of nitrous oxide/analgesia, anxiolysis (D9230) which the Plan 
denied as not being a covered service. The 2021 Evidence of Coverage states that anesthesia is covered as 
needed with covered procedures. The contract does not indicate any specific conditions in which anesthesia 
would not be covered, nor does it list specific types of anesthesia that are covered. The record shows that you 
received an extraction, which is a covered service, and you reasonably believed the inhalation of nitrous 
oxide/analgesia, anxiolysis (D9230) would be covered. Therefore, we decided that the Plan has to pay for the 
inhalation of nitrous oxide/analgesia, anxiolysis (D9230).  
 
We also decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140) or pay more for the 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 (D0140) is not among those covered under this benefit. The contract clearly states that you are 
responsible for a 50% coinsurance for the allowed two covered extractions per year. Therefore, we decided that 
the Plan does not have to pay for the problem focused limited oral evaluation (D0140) or pay more for the 
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.