Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the extensive 
oral evaluation (D0160), the intraoral complete series of radiographic images (D0210), a diagnostic cast 
(D0470), the panoramic radiographic image (D0330), a 2D photographic image (D0350), the surgical 
placement of implant body (D6010) for tooth #4, #7, #10, #13, #20, #23, #26, and #29, a prefabricated 
abutment (D6056) #4, #7, #10, #13, #20, #26, and #29, an abutment supported to crown (D6058) for tooth #23, 
the radiographic implant index (D6190), an implant supported to denture (D6118 and D6119), an extraction 
(D7140) for tooth #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #1,1 #12, #13, #14, #15, #18, #20, #21, #22, #23, #24, 
#25, #26, #27, and #28, a complicated suture (D7912) for tooth #1, and sedation (D9239 and D9243) provided 
by an out-of-network provider on April 12, 2023, and May 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services and 
portions of it should be reimbursed since they are the same as receiving dentures. The Plan denied your request. 
The Plan says the comprehensive oral evaluation, the intraoral complete series of radiographic images, the 
panoramic radiographic image, the extractions, and sedation were received from an out-of-network provider 
and are not covered by your supplemental benefits. Also, the extensive oral evaluation, the diagnostic cast, the 
2D photographic image, the implant supported to dentures, complicated suture, and implants and all related 
services are not covered by the Plan. 
 
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. 
 
The record shows you received the comprehensive oral evaluation, the intraoral complete series of radiographic 
images, the panoramic radiographic image, the extractions, and sedation from an out-of-network provider. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive oral evaluation, the 
intraoral complete series of radiographic images, the panoramic radiographic image, the extractions, and 
sedation are not covered under this benefit when received from an out-of-network provider. The extensive oral 
evaluation, the diagnostic cast, the 2D photographic image, the implant supported to dentures, complicated 
suture, and implants and all related services are not covered under the plan's dental benefit. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the extensive oral 
evaluation (D0160), the intraoral complete series of radiographic images (D0210), a diagnostic cast (D0470), 
the panoramic radiographic image (D0330), a 2D photographic image (D0350), the surgical placement of 
implant body (D6010) for tooth #4, #7, #10, #13, #20, #23, #26, and #29, a prefabricated abutment (D6056) #4, 
#7, #10, #13, #20, #26, and #29, an abutment supported to crown (D6058) for tooth #23, the radiographic 
implant index (D6190), an implant supported to denture (D6118 and D6119), an extraction (D7140) for tooth 
#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #1,1 #12, #13, #14, #15, #18, #20, #21, #22, #23, #24, #25, #26, #27, 
and #28, a complicated suture (D7912) for tooth #1, and sedation (D9239 and D9243) provided by an out-of-
network provider on April 12, 2023, and May 12, 2023.