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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes: 
We cover the following services when rendered by a Participating Provider: 
?Routine Preventive Dental Care 
?Periodic Oral or Comprehensive Exams (2per year) 
?Prophylaxis (Cleaning) (2 per year) 
?Fluoride Treatment (2 per year) 
?Dental x-rays 
X-Rays include: 
?Complete Series including bitewing single film (1 per 36 months)  
?Single film (1 per year) and bitewing single film (1 per year) 
?Bitewing2film (1 per year) and bitewing4 film (1 per year) 
?Panoramic film (1 per 36 months) 
?Occlusal Film (2 per year) 
?Temporomandibular joint film (1 per year) 
?Additional x-ray (1 per year) 
Comprehensive Dental: 
?Simple extraction or surgical removal of erupted tooth / 2 procedures per year 
?Resin filling or restoration / 2 procedures per year 
?Full mouth debridement / 1 per 2 years 
?Scaling/root planing limited to 1 procedure per quadrant per year. Scaling/root planing for 4 total procedures 
per year (deep cleaning) 
?Porcelain/ceramic or porcelain fused to high noble metal crown/ 1 tooth per year 
?Partial or full dentures / 1 per 5 years 
Limitations: 
?Services must be performed by a participating general dentist. 
?Denture coverage is limited to the following dentures: 
oD5110 ?complete upper denture 
oD5120 ?complete lower denture 
oD5130 ?immediate upper denture 
oD5140 ?immediate lower denture 
oD5211 ?partial upper, resin base 
oD5212 ?partial lower, resin base 
oD5213 ?partial upper, cast metal base 
oD5214 ?partial lower, cast metal base 
?Periodontal maintenance (Dental code: D4910), gingival irrigation (D4921), and localized delivery of 
antimicrobial agents (D4391), like Arestin?, are not covered and the member is responsible for the additional 
charge, even though scaling/root planing (D4341 and D4342) is covered. 
?Core build-up (D2950) is not covered and the member is responsible for the additional charge, even though 
one crown is covered. 
?Prior Authorization may be required and must be received by the plan?s dental vendor from a participating 
dental provider 
You can find this information on pages 65-67 of the Plan?s 2020 Evidence of Coverage (EOC).