Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), an extensive oral 
evaluation (D0160), the intraoral complete series of radiographic images (D0210), a diagnostic cast (D0470), a 
2D photographic image (D0350), a cone beam (D0367),  the surgical placement of implant body (D6010) for 
tooth #4, #7, #10, #13, #20, #23, #26, and #29, an abutment (D6056) for tooth #4, #7, #10, #13, #20, #23, #26, 
and #29, the surgical removal of implant body (D6100) for tooth #5 and #29, a surgical implant index (D6190), 
an implant to fixed denture (D6118 and D6119), an extraction (D7140) for tooth #5, #20, #29, and extraction 
(D7210) for tooth #2, #4, #6, #7, #8, #9, #10, #11, #12, #18, #21, #22, #23, #24, #25, #26, #27, #28, #20, and 
#31, the complicated suture (D7912), anesthesia (D9215), sedation (D9239 and D9243) provided by The 
Wheelchair Store on February 15, 2022, and March 15, 2022. We also decided that the Plan does not have to 
pay more for the diagnostic cast (D0470), the intraoral radiographic image (D0220), the panoramic 
radiographic image (D0330), the modification of removable prothesis (D5875) provided by an out-of-network 
provider on July 18, 2022, January 23, 2023, and February 23, 2023 
 
You asked the Plan to pay more for the dental services. You say that you were not aware that you had dental 
coverage and you filed your claim late because you did not know you could. The Plan denied your request. The 
Plan says you are responsible for any charged amount above the Plan's cost-sharing amount when your 
services are received from an out-of-network provider. Also, the diagnostic cast was not covered by the Plan in 
2022. The claims for February 15, 2022, and March 15, 2022, was filed later than the close of the period ending 
1 calendar year after the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
The record shows that the claims for February 15, 2022, and March 15, 2022, was not filed until March 16, 
2023. This means that more than one calendar year from the date of service had passed before a claim was 
filed. You have also been asked to pay the difference between the out-of-network provider's charges and the 
Plan's payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
The diagnostic cast was not covered under the Plan's 2022 dental benefit. Therefore, we decided that the Plan 
does not have to pay for a comprehensive oral evaluation (D0150), an extensive oral evaluation (D0160), the 
intraoral complete series of radiographic images (D0210), a diagnostic cast (D0470), a 2D photographic image 
(D0350), a cone beam (D0367),  the surgical placement of implant body (D6010) for tooth #4, #7, #10, #13, 
#20, #23, #26, and #29, an abutment (D6056) for tooth #4, #7, #10, #13, #20, #23, #26, and #29, the surgical 
removal of implant body (D6100) for tooth #5 and #29, a surgical implant index (D6190), an implant to fixed 
denture (D6118 and D6119), an extraction (D7140) for tooth #5, #20, #29, and extraction (D7210) for tooth #2, 
#4, #6, #7, #8, #9, #10, #11, #12, #18, #21, #22, #23, #24, #25, #26, #27, #28, #20, and #31, the complicated 
suture (D7912), anesthesia (D9215), sedation (D9239 and D9243) provided by The Wheelchair Store on 
February 15, 2022, and March 15, 2022. Therefore, we also decided that the Plan does not have to pay more for 
the diagnostic cast (D0470), the intraoral radiographic image (D0220), the panoramic radiographic image 
(D0330), the modification of removable prothesis (D5875) provided by an out-of-network provider on July 18, 
2022, January 23, 2023, and February 23, 2023