Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210), and gingival irrigation with a medicinal agent  per quadrant (D4921) provided on June 28, 2023. We 
also decided that the Plan does not have to waive the copayment for the periodontal scaling and root planing - 
four or more teeth per quadrant (D4341), and periodontal scaling and root planing  one to three per quadrant 
(D4342). 
 
You asked the Plan to pay for the intraoral  comprehensive series of radiographic images and the gingival 
irrigation with a medicinal agent  per quadrant. You also asked the Plan to waive the copayment for the 
periodontal scaling and root planing - four or more teeth per quadrant (D4341), and periodontal scaling and 
root planing  one to three per quadrant. You say that the doctor did not tell you to pay $533, did not explain 
the plans decision or pay attention to your concerns. The Plan denied your request. The Plan says your benefit 
for the intraoral  comprehensive series of radiographic images has already been exhausted and there is no 
coverage for gingival irrigation. Your Plan clearly says that you must pay a $25 copayment for the periodontal 
scaling and root planing - four or more teeth per quadrant and periodontal scaling and root planing  one to 
three per quadrant provided in-network. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral  comprehensive series of radiographic images was exhausted on date of 
service August 9, 2023. Therefore, we decided that the Plan does not have to pay for the intraoral  
comprehensive series of radiographic images (D0210) provided on June 28, 2023.  
 
You have been asked to pay a $25 copayment for the periodontal scaling and root planing - four or more teeth 
per quadrant and a $25 copayment for the periodontal scaling and root planing  one to three per quadrant. 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 copayment for the periodontal scaling and root planing - four or more teeth 
per quadrant and periodontal scaling and root planing  one to three per quadrant provided on June 28, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the gingival irrigation with a medicinal 
agent  per quadrant is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the gingival irrigation with a medicinal agent  per quadrant (D4921) provided on June 28, 
2023. 
 
Your complaint about your experience with the doctor is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.