Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for general anesthesia - first 15-minute (D9222), general 
anesthesia - each subsequent 15-minute increment (D9223) and extraction, erupted tooth requiring removal of 
bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) Tooth #14 
and #19 provided on November 9, 2022. We decided that the Plan does not have to pay for limited oral exam 
(D0140), unspecified oral surgery procedure, by report (surgical tray setup) (D7999) and therapeutic parenteral 
drug, single administration (D9610) provided on November 9, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the amount of reimbursement from the 
enrollee's insurance was not acceptable. You say that insurance should pay 100% of the billed amount. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. Enrollees must pay 50% 
coinsurance for covered out-of-network dental services and may be billed by the out-of-network provider for 
any charged amount greater than the payment made by the Plan. This benefit includes the requested D0140 but 
is limited to twice per calendar year. This benefit includes only those items and services specifically listed in 
your Plan contract.  Unspecified oral surgery procedure, by report (surgical tray setup) (D7999) and therapeutic 
parenteral drug, single administration (D9610) are not covered under the Plans dental benefits. 
 
The allowed amounts of the covered dental services total $720, resulting in a coinsurance amount of  $360 + 
$100 deductible = $460 and a Plan payment of $360. 
 
You may also be 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 general anesthesia - first 15-minute (D9222), general 
anesthesia - each subsequent 15-minute increment (D9223), extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) Tooth #14 and 
#19 provided on November 9, 2022. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, codes D7999 and D9610 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
unspecified oral surgery procedure, by report (surgical tray setup) (D7999) and therapeutic parenteral drug, 
single administration (D9610) provided on November 9, 2022. 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered oral exams on January 27, 2022, and August 30, 2022. Therefore, these benefits 
were exhausted as of November 9, 2022. Therefore, we decided that the Plan does not have to pay for limited 
oral exam (D0140) provided on November 9, 2022.