Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350) x2, detailed and extensive oral evaluation - problem focused, by report (D0160) x2, 
diagnostic casts (D0470) x2, cone beam CT capture and interpretation with field of view of both jaws; with or 
without cranium (D0367) x2, local anesthesia in conjunction with operative or surgical procedures (D9215), 
implant/abutment supported interim fixed denture for edentulous arch  maxillary (D6119), implant/abutment 
supported interim fixed denture for edentulous arch  mandibular (D6118), complicated suture - greater than 5 
cm (D7912), intravenous moderate (conscious) sedation/ analgesia  each subsequent 15-minute increment 
(D9243) x5, surgical placement of implant body: endosteal implant (D6010) x8, prefabricated abutment  
includes modification and placement (D6056) x8, radiographic/surgical implant index, by report (D6190) x2, , 
panoramic radiographic image (D0330) and provided on August 16, 2022, to December 7, 2022. We decided 
that the Plan does not have to pay more for intraoral  complete series of radiographic images (D0210) x2 
provided on August 16, 2022, to December 7, 2022. 
 
You asked the Plan to pay for  the dental services. You say that you hope your insurance will help cover the 
cost because you have post-traumatic stress disorder (PTSD) and had loose teeth that needed to be taking care 
of. The Plan denied your request. The Plan says some services are not covered under your Plan, your benefit 
for some of the requested items or services 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. This benefit includes only 
those items and services specifically listed in your Plan contract. D0350, D0160, D00470, D0367, D9215, 
D6119, D6118, D7912, D9243, D6010, D6056 and D6190 are not covered under the Plans dental benefits.  
This benefit includes the requested D0210 and D0330 but is limited to one procedure code every five calendar 
years. The contract also says that enrollees may be billed by the out-of-network provider for any charged 
amount greater than the payment made by the Plan. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for D0210. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D0210 on August 16, 2022. Therefore, this benefit has been exhausted. Although 
two different services were received, they fall within the same category in your Evidence of Coverage and are 
subject to the same frequency limitations. Therefore, we decided that the Plan does not have to pay for D0210 
and D0330 provided on August 22, 2022, and December 7, 2022. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0350 x2, D0160 x2, 
D0470) x2, D0367 x2, D9215, D6119, D6118, D7912, D9243 x5, D6010 x8, D6056 x8 and D6190 x2 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay dental 
services provided on August 16, 2022, to December 7, 2022.