Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) and three surgical 
extractions (D7210 x3). We decided that the Plan does not have to pay for the cone beam computed 
tomography (CT) capture and interpretation (D0364) and three bone replacement grafts for ridge preservation 
(D7953 x3).  
 
You asked the Plan to pay for the comprehensive oral evaluation (D0150), cone beam computed tomography 
(CT) capture and interpretation (D0364), three surgical extractions (D7210 x3), and three bone replacement 
grafts for ridge preservation (D7953 x3) provided on October 27, 2021. You say that you fell and fractured 
your maxilla and lost five teeth. You also say that the dentist and Medicare sent you to a surgeon to repair the 
maxilla, remove remnants of teeth, and rebuild your upper jaw surgically. The Plan says that you were referred 
to an OON oral surgeon who does not accept Medicare. The Plan also says that tooth extractions and accidental 
injury are not covered by the dental plan. 
 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) and three surgical 
extractions (D7210 x3).  
 
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 the 
comprehensive oral evaluation (D0150) and three surgical extractions (D7210 x3) when the services are 
medically necessary and reasonable. 
 
The record shows that these services were rendered by an out-of-network provider as a result of a fall where 
you fractured your maxilla and lost several teeth. The 2021 Evidence of Coverage states services obtained from 
an out-of-network dentist will not be covered, except if there is a dental emergency. The contract also lists 
comprehensive oral evaluation (D0150) and surgical extraction (D7210) as covered benefits. The record does 
not show that you received dental treatment for crowns, bridges and/or dentures. The documentation shows that 
you paid for these services up front. We believe these services were provided on an emergency basis. 
Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation (D0150) and three 
surgical extractions (D7210 x3).  
 
We also decided that the Plan does not have to pay for the cone beam computed tomography (CT) 
capture and interpretation (D0364) and three bone replacement grafts for ridge preservation (D7953 x3). 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam computed tomography (CT) capture and interpretation (D0364) and three bone replacement grafts for 
ridge preservation (D7953 x3). 
 
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.