Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for pin retention services (D2951) provided on September 19, 2022. This also means that the Plan does not have to waive the cost-sharing applied to a limited oral evaluation (D0140), intraoral - periapical first radiographic imaging (D0220), core buildup (D2950), pin retention services (D2951), and a crown - porcelain fused to predominantly base metal (D2751) provided on February 14, 2022. The Plan does not have to waive the cost-sharing applied to intraoral - periapical first radiographic imaging, core buildup (D2950), and a crown - porcelain fused to predominantly base metal (D2751) provided on September 19, 2022. The Plan does not have to pay for a limited oral evaluation (D0140) provided on September 19, 2022.

You asked the Plan to pay for any denied dental services and to adjust the cost-sharing applied to any paid dental services billed for dates of service February 14, 2022, and September 19, 2022. You say that the denial reasons make no sense and that some have member responsibilities applied and some do not. You say that these claims need to be looked at again. The Plan says that the claims processed appropriately. 

We decided that the Plan has to pay for pin retention services (D2951) provided on September 19, 2022. 

The Plan follows Medicare rules. Medicare rules say that health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward us information regarding their denial reason for code D2951 billed for date of service September 19, 2022. Without this information, we are unable to make a determination regarding the Plan's denial. The claim for date of service February 14, 2022, paid 50% on the cost of code D2951 for tooth #12. This supports that it is a covered service under the restorative benefits. The Plan has not substantiated their denial of one of the D2951 codes billed for tooth #2 for date of service September 19, 2022.

We also decided that the Plan does not have to waive the cost-sharing applied to a limited oral evaluation (D0140), intraoral - periapical first radiographic imaging (D0220), core buildup (D2950), pin retention services (D2951), and a crown - porcelain fused to predominantly base metal (D2751) provided on February 14, 2022. The Plan does not have to waive the cost-sharing applied to intraoral - periapical first radiographic imaging (D0220), core buildup (D2950), and a crown - porcelain fused to predominantly base metal (D2751) provided on September 19, 2022. The Plan does not have to pay for a limited oral evaluation (D0140) provided on September 19, 2022.

The Plan follows Medicare rules. Medicare rules say that a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% coinsurance for all covered Class 2 Basic Services after a $100 deductible, and a 50% coinsurance for all covered Class 3 Major Services, after a $100 deductible. Your contract with the Plan also clearly says that coverage for problem focused oral evaluations are only covered once every 12 months. 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.

You were asked to pay the entire allowed amount (totaling $53.51) for a limited oral evaluation (D0140) provided on February 14, 2022. This amount was applied to your $100 deductible. This service falls within the Class 2 Basic Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $100 deductible for Class 2 Basic Services. This cost-sharing is a contractual obligation that had not yet been met. Therefore, the Plan does not have to waive the deductible applied to a limited oral evaluation provided on February 14, 2022. 

You were asked to pay the entire allowed amount (totaling $18.66) for intraoral - periapical first radiographic imaging (D0220) provided on February 14, 2022. This amount was applied to your $100 deductible. This service falls within the Class 2 Basic Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $100 deductible for Class 2 Basic Services. This cost-sharing is a contractual obligation that had not yet been met. Therefore, the Plan does not have to waive the deductible applied to intraoral - periapical first radiographic imaging (D0220) provided on February 14, 2022. 

You were asked to pay a 50% coinsurance (totaling $97.93) for core buildup (D2950) provided on February 14, 2022. This service falls within the Class 3 Major Services benefit category. 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, the Plan does not have to waive the coinsurance applied to core buildup (D2950) provided on February 14, 2022. 

You were asked to pay $27.83 towards the cost of a crown - porcelain fused to predominantly base metal (D2751) provided on February 14, 2022. This amount was applied to your $100 deductible. This service falls within the Class 3 Major Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $100 deductible for Class 3 Major Services. 

This cost-sharing is a contractual obligation that had not been yet met. Once the $27.83 was applied as your liability, your $100 deductible was met. You were then asked to pay a 50% coinsurance on the remaining balance due (totaling $353.95) for a crown - porcelain fused to predominantly base metal (D2751) provided on February 14, 2022. This service falls within the Class 3 Major Services benefit category. 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, the Plan does not have to waive the coinsurance applied to a crown - porcelain fused to predominantly base metal (D2751) provided on February 14, 2022. 

You were asked to pay a 50% coinsurance (totaling $18.35) for pin retention services (D2951) provided on February 14, 2022. This service falls within the Class 3 Major Services benefit category. 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, the Plan does not have to waive the coinsurance applied to pin retention services (D2951) provided on February 14, 2022. 

You were asked to pay a 50% coinsurance (totaling $9.33) for intraoral - periapical first radiographic imaging (D0220) provided on September 19, 2022. This service falls within the Class 2 Basic Services benefit category. 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, the Plan does not have to waive the coinsurance applied to intraoral - periapical first radiographic imaging (D0220) provided on September 19, 2022.

You were asked to pay a 50% coinsurance (totaling $97.93) for core buildup (D2950) provided on September 19, 2022. This service falls within the Class 3 Major Services benefit category. 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, the Plan does not have to waive the coinsurance applied to core buildup (D2950) provided on September 19, 2022.

You were asked to pay a 50% coinsurance (totaling $367.87) for a crown - porcelain fused to predominantly base metal (D2751) provided on September 19, 2022. This service falls within the Class 3 Major Services benefit category. 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, the Plan does not have to waive the coinsurance applied to a crown - porcelain fused to predominantly base metal (D2751) provided on September 19, 2022.

Though the Plan offers dental benefit in excess of Medicare coverage, coverage for problem focused oral evaluations is limited to once every 12 months. The records show that the Plan had already applied your benefits to a problem focused oral evaluation provided on February 14, 2022. This exhausted your benefit for this type of service for a 12-month period. Therefore, the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 19, 2022. 

We have included a chart below to demonstrate the codes in dispute and how they processed

Date of Service	Code 	Dentist's Charge	Allowed Amount	Deductible Applied	Coinsurance
Applied	Total Enrollee Liability 	
February 14, 2022	D0140	$99	$53.51	$53.51		$53.51	
February 14, 2022	D0220	$37	$18.66	$18.66		$18.66	
February 14, 2022	D2950	$316	$195.85		$97.93 (50%)	$97.93	
February 14, 2022	D2740		Alternate procedure paid (D2751)				
February 14, 2022	D2751	$1,583	$735.73	$27.83	$353.95 (50%)	$381.78	
February 14, 2022	D2951	$38	$36.70		$18.35 (50%)	$18.35	
February 14, 2022	D2951		Duplicate charge, no enrollee liability 				
September 19, 2022	D0140	$99				$99	
September 19, 2022	D0220	$37	$18.66		$9.33 (50%)	$9.33	
September 19, 2022	D2950	$316	$195.85		$97.93 (50%)	$97.93	
September 19, 2022	D2951		Duplicate charge, no enrollee liability				
September 19, 2022	D2951		Duplicate charge, no enrollee liability				
September 19, 2022	D2740		Alternate procedure paid (D2751)				
September 19, 2022	D2751	$1,583	$735.73		$367.87	$367.87	
Total						$1,144.36	

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.