Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330), bitewings - four 
radiographic images (D0274), intraoral - periapical first radiographic image (D0220), each additional 
radiographic image (D0230), 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), 
3D dental surface scan  direct (D0801), maxillary partial denture - flexible base (including retentive/clasping 
materials, rests, and teeth) (D5225), crown - porcelain/ceramic (D2740), core buildup, including any pins when 
required (D2950), consultation - diagnostic service provided by dentist or physician other than requesting 
dentist or physician (D9310), therapeutic parenteral drugs, two or more administrations, different medications 
(D9612), inhalation of nitrous oxide/analgesia, anxiolysis (D9230) intravenous moderate (conscious) 
sedation/analgesia- first 15 minutes (D9239), each subsequent 15 minute increment (D9243), extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal 
flap if indicated (D7210), and alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, 
per quadrant (D7311), provided on March 17, 2023, to April 19, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D0330, D0274, D0220, D0230, D0350, 
D0801, D5225, D2740, D2950, D9310, D9612, D9230, D9239, D9243, D7210, and D7311. You say that you 
provided the dental office with a copy of your member identification card. You also say that they checked with 
the insurance company and that they were in-network with your plan. The Plan denied your request. The Plan 
says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits. The Plan also say only specific dental services are included in your dental coverage.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for panoramic radiographic image (D0330), bitewings - four radiographic images (D0274), intraoral - 
periapical first radiographic image (D0220), each additional radiographic image (D0230), 2D oral/facial 
photographic image obtained intra-orally or extra-orally (D0350), 3D dental surface scan  direct (D0801), 
maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth) (D5225), 
crown - porcelain/ceramic (D2740), core buildup, including any pins when required (D2950), consultation - 
diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310), 
therapeutic parenteral drugs, two or more administrations, different medications (D9612), inhalation of nitrous 
oxide/analgesia, anxiolysis (D9230) intravenous moderate (conscious) sedation/analgesia- first 15 minutes 
(D9239), each subsequent 15 minute increment (D9243), extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), and 
alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311), 
provided on March 17, 2023, to April 19, 2023.