Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the panoramic x-ray, implant, bone replacement graft and surgical 
extraction. We decided that the Plan does not have to pay for the detailed and extensive oral evaluation.  
 
You asked the Plan to pay for the dental services. You say that you participate in the Plan's dental network and 
these claims should be paid. The Plan says that the provider in this case has chosen to opt-out of Original 
Medicare and therefore is not eligible for federal payment. 
 
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. 
 
We decided that the Plan has to pay for the panoramic x-ray, implant, bone replacement graft and 
surgical extraction.  
 
We looked at the file and Medicare rules. The Plan denied payment for these services on the basis that the 
provider has opted-out of Original Medicare. Normally, providers who have opted-out of Medicare are unable 
to receive payments for Medicare plans for medical services. However, the Centers for Medicare and Medicaid 
Services (CMS) has stated that opt-out provisions do not apply to supplemental benefits unless the Plan 
specifically states this limitation in the contract. Dental services are not covered by Medicare and are instead 
covered by a supplemental benefit offered by the Plan. Opt-out rules do not prevent a provider from being paid 
for non-Medicare covered benefits. 
 
The Plan's contract does not state that supplemental dental care may only be received from a provider that 
participates in Original Medicare. It does state that services must be received from a licensed dentist who 
participates in the Plan's specified dental network. We were able to verify on the Plan's website by following 
the instructions in the contract that the provider in this case is part of the Plan's dental network. 
 
The Plan lists panoramic x-rays, implants, extractions and oral surgery as covered services under this benefit. 
The Plan has not provided any further information to argue why these services should be denied. Based on this 
information, we decided that the Plan's rules for coverage of these dental services have been met. Therefore, 
we decided that the Plan has to pay for the panoramic x-ray (D0330) provided on July 1, 2021, and the implant 
placement (D6010), bone replacement graft (D7953) and surgical extraction (D7210) provided on July 16, 2021. 
 
We also decided that the Plan does not have to pay for the detailed and extensive oral evaluation. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, a detailed and extensive oral 
evaluation is not listed among those services covered under this benefit. The Plan specifies that routine exams 
are covered but there is no mention of coverage for problem-focused exams. Therefore, we decided that the 
Plan does not have to pay for the detailed and extensive oral evaluation (D0160) provided on July 1, 2021. 
 
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.