Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the periodontal scaling and root planing - 
four or more teeth per quadrant (D4341), periodontal scaling and root planing - one to three teeth per quadrant 
(D4342), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including 
elevation of mucoperiosteal flap if indicated (D7210), and resin-based composite - four or more surfaces, 
posterior (D2394) provided on August 29, 2022, to October 18, 2022. 
 
You asked the Plan to waive the cost share for the dental services represented by codes D7210 for tooth #2 and 
3, D4341, D4342 and D2394. You also asked the Plan to pay for the extractions (D7210) of tooth #5 and 29. 
You say that you dont have another insurance and do not have enough money to pay this amount. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. The Plan also says that your benefit 
for the extractions (D7210) has already been exhausted. 
 
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. 
 
You have been asked to pay a total of $915.60 for the dental services. 
 
DATE OF 
SERVICE 
 
CODE 
 
ALLOWED 
AMOUNT 
 
COINSURANCE 
AMOUNT YOU 
OWE 
9/14/2022 D7210 tooth #2 $344.00 50% $86.00 
9/14/2022 D7210 tooth #3 $344.00 50% $86.00 
9/14/2022 D7210 tooth #5 $172.00 - $172.00 
9/14/2022 D7210 tooth #29 $172.00 - $172.00 
9/22/2022 D4341 $157.00 70% $109.90 
9/22/2022 D4342 $318.00 70% $172.00 
10/18/2022 D2394 $214.00 55% $117.70 
TOTAL    $915.60 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the extractions tooth #5 and 29 was exhausted on date of service September 14, 2022. 
Therefore, we decided that the Plan does not have to pay for extractions, erupted tooth requiring removal of 
bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated on September 14, 
2022. 
  
The dental services at issue are covered by the Plans dental benefits, however you are responsible for a share 
of the costs as described above. These services fall within the dental services benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan.  
 
Therefore, we decided that the Plan does not have to waive the cost share for the periodontal scaling and root 
planing - four or more teeth per quadrant (D4341), periodontal scaling and root planing - one to three teeth per 
quadrant (D4342), resin-based composite - four or more surfaces, posterior (D2394), and the extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated tooth #2 and 3 (D7210). We also decided that the Plan does not have to pay for the extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated tooth #5 and 29 (D7210) provided on August 29, 2022, to October 18, 2022.