Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the comprehensive periodontal evaluation (code D0180) and the 
intraoral - complete series of radiographic images (code D0210) provided on January 6, 2022, and the 
tooth extraction (code D7210) provided on January 25, 2022. We decided that the Plan does not have to pay 
for the periodontal scaling and root planing (code D4341) provided on December 20, 2021, the unspecified 
periodontal procedure (code D4999) and the occlusal adjustment (code D9951) provided on January 25, 2022, 
and the unspecified periodontal procedure (code D4999) and the occlusal adjustment (code D9951) provided 
on February 2, 2022.  
 
You asked the Plan to pay for the dental scaling and root planing, evaluation, images, extraction, adjustments, 
and unspecified periodontal procedures. You say that you were told by your doctor that this procedure was 
necessary. The Plan says that the periodontal scaling and root planing (code D4341) provided on December 20, 
2021 is not a covered dental service of your supplemental benefits. The Plan also says that the services 
provided on January 6, 2022, January 25, 2022, and February 2, 2022 were performed by a non medicare 
contracted provider, and therefore are not covered by the Plan. 
 
We decided that the Plan has to pay for the comprehensive periodontal evaluation (code D0180) and the 
intraoral - complete series of radiographic images (code D0210) provided on January 6, 2022, and the 
tooth extraction (code D7210) provided on January 25, 2022.  
 
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.  
 
The Plan covers dental evaluations, images, and extractions when the services are medically necessary and 
reasonable.  
 
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 did not provide us with adequate information regarding the provider, 
for dates of service from January 6, 2022, to February 2, 2022, on their Medicare contract status. The Plan also 
did not provide information clarifying the enrollee's complete covered benefits, specifically if the enrollee had 
the optional supplemental dental benefits included in their coverage. Therefore, we decided that the Plan has to 
pay for the comprehensive periodontal evaluation (code D0180) and the intraoral - complete series of 
radiographic images (code D0210) provided on January 6, 2022, and the tooth extraction (code D7210) 
provided on January 25, 2022.  
 
We also decided that the Plan does not have to pay for the periodontal scaling and root planing (code 
D4341) provided on December 20, 2021, the unspecified periodontal procedure (code D4999) and the 
occlusal adjustment (code D9951) provided on January 25, 2022, and the unspecified periodontal 
procedure (code D4999) and the occlusal adjustment (code D9951) provided on February 2, 2022. 
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, dental scaling and root planing, 
occlusal adjustment, and unspecified periodontal procedures are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (code 
D4341) provided on December 20, 2021, the unspecified periodontal procedure (code D4999) and the occlusal 
adjustment (code D9951) provided on January 25, 2022, and the unspecified periodontal procedure (code 
D4999) and the occlusal adjustment (code D9951) provided on February 2, 2022. 
 
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.